Dear Doctor

“First do no harm.” Probably most people don’t realize that this isn’t even actually part of the oath that you may or may not have taken when you became a doctor. I think most people don’t know a lot about what it’s like to be a doctor, or what being a doctor meant to you when you started med school, or what it means to you now. I’m pretty sure you have pressures on you that most of us don’t know about or understand, that you are nearly as much a victim of a system that does not care about patients as are your patients. I know your job is hard, and I understand that you are human, and fallible, and that people expect unreasonable things from you, and that is a lot to deal with. I understand.

I still need to talk to you about doing no harm. Even if that was not an oath that you agreed to, and even if that seems like a tall order when medicine is messier and more human than pop culture makes it out to be, I still think it is a fair expectation. I think it is fair for patients to expect to consult your expertise and not come away worse for the experience.

I can’t speak to all of the other ways in which doctors sometimes cause harm to their patients, I only know how I have been harmed as a fat person. So I will tell you how to do better when you meet people like me.

I am fat. This is not a temporary condition and you do not have a cure. Diets do not work. I know this because I have spent my life bouncing from diet to diet in search of the one that will finally fix the fatness that doctors like you told me was definitely deadly, definitely fixable, and definitely my own fault. I have engaged in disordered eating behaviors (and at several points could have been diagnosed with an eating disorder if doctors had been concerned about my behaviors instead of encouraging them). I cannot think of a time in my life until very recently when I was not either attempting to lose weight or rebounding from those attempts. I have spent my entire adult life trying to change my body, and it is not changing. I am fat, that is just a fact, and I need to accept that and work with it.

I need you to do that for me, also. I need you to recognize that, even if my risk of a particular disease process is heightened because of my size (which is not a clear-cut as we have all been led to believe), that is simply the set of circumstances that exist in my health portfolio. It is not something that I can change – and not for lack of trying – and it is not good medicine to focus on the most difficult, least changeable thing and ignore everything else that could help me.

This is my body, and it is your ethical obligation to treat it with the same care and compassion you offer to thin people. I am not asking for special treatment. I am asking for the same treatment. I am asking for evidence-based, compassionate, whole-person care.

Going to the doctor causes me considerable anxiety. My fight or flight mode is activated as soon as I wake up on the day of my appointment and it doesn’t shut off until long after, sometimes a day or two – especially when the appointment goes as poorly as I feared it would. As it often does. Here is an incomplete list of my experiences which explain this apprehension:

  • When I was diagnosed with PCOS almost 20 years ago, I was told that my weight caused it and losing weight would basically cure it. I was not offered anything beyond weight loss to manage my symptoms and no doctor ever explained to me that PCOS was more than just a reproductive issue. I was shocked to meet a thin woman who also had PCOS (because I had been told it was caused by my fatness); she assumed that I was on Metformin like she was, because her experience with the diagnosis and treatment of PCOS was drastically different from mine despite the major underlying concern – insulin resistance – applying equally to us both. No doctor ever told me that insulin resistance was part of PCOS, and despite the many times I was screened for diabetes, no doctor ever told me that my PCOS – rather than merely my body size – was a reason to screen for diabetes regularly. In other words, despite considerable time, energy, effort, money, and anxiety spanning decades, instead of the most basic information about my specific health concerns, I got generic catch-all fat person advice that made my health worse, not better, and paid countless doctors for what I consider very negligent care.
  • Nearly every doctor I have seen in my adult life has either recommended an extremely restrictive diet, a fad diet, weight loss pills, or weight loss surgery, regardless of my presenting concern and regardless of the state of my metabolic or other health markers, without any discussion of the drawbacks, without asking if I was interested in this counsel, and without considering the possibility of an eating disorder.
  • I have overheard medical staff making disparaging comments about my body and my appearance in an area where other patients could hear them. I have had more than one doctor make disparaging comments to my face. A gynecologist who had given me muscle relaxers to make the endometrial biopsy easier (for her, not for me, as it turns out) became frustrated that my legs did not easily open wide enough and disgustedly told me that it was my fault because I didn’t take care of myself. There was a medical student observing her at the time, as well as a medical assistant. Nobody commented or reacted, and I was impaired by the muscle relaxer and could not defend myself, so I cried the rest of the day. When I returned for the follow-up, I called her medical student into the office with me so I could explain that what she did was unacceptable and I deserve more respectful care, she dismissed me in the same clipped tones. I went to retrieve my medical file and found that her synopsis of these events was “grossly morbidly obese; advised weight reduction to improve symptoms, but patient became defensive”.
  • When I began having gallbladder attacks, I went to my primary care doctor, to several different urgent care clinics, and to several emergency rooms over the course of six months of increasingly severe attacks. The treatment I received ranged from a recommendation to eat less greasy food (despite the fact that I was terrified to eat anything most of the time because even lettuce would cause an attack and that doctor did not bother to ask about my diet in general or that day in particular), to the standard weight loss advice fat people always get, to one curious referral to a cardiologist despite a totally normal heart workup (I was 29 and have no family history of heart disease or heart attacks). None of these doctors ordered an ultrasound of my abdomen, which I understand is a pretty commonplace diagnostic step when faced with my (fairly textbook) symptoms. It took six months of torturous attacks culminating in emergency surgery to diagnose and treat my gallstones. I cannot be sure if this is solely a result of weight bias, but each individual appointment included assumptions and mischaracterizations (including one accusation of exaggerating my pain) that definitely were a function of weight bias.
  • A gynecologicist who performed a D&C on me persisted in recommending weight loss long after I clearly explained that I was not interested in discussing it and simply needed treatment for my hyperplasia. Ultimately he attempted to sell me diet bars made primarily of fiber that he said would trick my body into thinking I wasn’t hungry and allow me to eat only 800 calories a day. When I firmly and frustratedly rejected his fad diet, our rapport crumbled and he shortly thereafter sent me a referral to a different doctor, citing workload changes I’m still not sure I believe.
  • At one point, because doctors had convinced me that I would definitely have *some* deadly disease by middle age if I did not go to any lengths necessary to drastically reduce my body size, I went to a presentation by a local bariatric surgery center on the Roux-en-Y gastric bypass. I work in university classrooms and I’ve been through enough bioscience classes to have multiple degrees (if I were getting credit), so I am reasonably well-versed (for a lay person) on biology and anatomy/physiology. When the surgeon explained the specifics of the surgery, I realized that some important steps in digestion could not possibly work the same afterwards. I raised my hand and asked if malnutrition was a concern, and she laughed and said “she’s here for weight loss surgery and she’s worried about malnutrition”. She never answered my question, just mocked me for asking it, and as it turns out, my question was medically insightful, since weight loss surgery recipients do, in fact, have permanent issues with nutrient absorption.

These are the incidents I remember. There are definitely more, and there is also the general frustration of constantly receiving counsel to improve my eating and exercise habits without first being asked what they even are, the noticeable displeasure some doctors display when they have to touch my body, the clear disposition that I read (based on experience) as a lack of investment in my care driven by a belief that I am not interested in my own health. Not to mention the consistent characterizing of each of all of my individual symptoms as separate weight-related ailments instead of acknowledging that nearly all of my medical history has been treatment of the collective symptoms of one disorder – PCOS. (arguably, even my gallstones are a result of my PCOS, in that they were most likely caused by my weight cycling, and I mostly pursued weight loss in an attempt to treat my PCOS symptoms).

I don’t believe that doctors do these things to me intentionally. I think they mostly don’t know they’re doing them. I think they don’t know that I understand what it means when they shrink back, don’t make eye contact, sigh, shrug, rush me out the door. I believe they most likely became doctors because they wanted to help people, and I believe they do many of these things because they don’t know what else to do. I believe that they – that you – are most likely good and compassionate and don’t mean to cause me harm. But in spite of all of this, the fact is that very often, you do. And the impact of these harmful incidents is cumulative. I have a wonderful primary care doctor now, and despite our great rapport, her willingness to offer weight-inclusive care, and her general pleasant disposition, I still wake up with anxiety on appointment days.

I know you don’t want me to feel this way. I know you most likely do care about your patients. I know you’re busy and overworked, and I know you are beholden to policies and “best practices” that you didn’t create for how to deal with bodies like mine. I am not asking you to take a bunch of workshops or to loudly defy the powers that dictate your compensation. I understand that you have hoops to jump through. I also understand that the status quo is pretty powerful, and despite mounting evidence that medical weight bias is causing harm and that the so-called obesity crisis is overblown, change is incredibly slow and we are stuck with what we have in the meantime. I know.

Here is what I do want: I want you to listen before you advise. Hear my actual concerns before you jump to a conclusion, especially if that conclusion is that my fat is causing my problem. Let that be a diagnosis of exclusion rather than your first impulse, because when you offer me that and only that, it is the same for me as if you are saying there is nothing you can do for me. If that is really true, okay, I accept that, but it is only actually true if a thin person who came to you with the same concerns would get the same answer. I want you to ask me the same questions you would ask a thin person, offer the same advice you would offer a thin person. I want you to think of other possible causes for my concerns besides my fat, and discuss all of them with me. I want you to respect the boundaries I put in place regarding measuring my weight or discussing weight loss, acknowledge those boundaries as a lack of consent, which I am entitled to.

I want you to recognize that mental health is an important part of my overall health picture, that focusing on my size is detrimental to my mental health, and, because I have a history of a clinically diagnosable eating disorder (even though weight bias ensured that I never got diagnosed or treated), weight loss is simply not a good solution for my health concerns because, no matter how much you may believe it would benefit my physical health, it would devastate my mental health. I want you to read up on Health At Every Size principles and Intuitive Eating principles, to expand your repertoire of possible treatment approaches for people who, like me, would experience worse overall health if weight became the focus of their care.

I want you to spend the same amount of time with me that you spend with thin patients, smile, talk to me, and touch me as much and in the same way as you do thin patients. You don’t need to do more for me than for them; if you are not one to smile, you don’t need to smile for me. If you don’t do small talk, you don’t need to do it for me. I just need you to reflect on whether your serious expression and clipped sentences are your general temperament or your emotional response to my fat body. I usually know, so I want you to notice this, too.

I believe you can provide me with the kind of care I need. I believe you want to help me. I hope we can have a better relationship moving forward, because I think that is essential to improving both the quality of the care I am receiving and the satisfaction you feel when providing it.

Thank you.

Thin Privilege vs Body Image: A Before and After Story

In the picture at the left, I am around 80 lbs smaller. I am still close to 300 lbs, still unambiguously fat, but I am much closer to the thin ideal. I can shop in brick and mortar stores. I can fly on an airplane without a seatbelt extender. I can sit in the exit row if I want to. People are nicer to me in general. Nobody makes faces when they see me boarding a plane. People hold doors for me and smile without me smiling first. Doctors are still mostly terrible to me, but they listen a little more because I am performing weight loss to their satisfaction. People include me in group photos and post said pictures on their social media. I fit in every restaurant chair, amusement park ride, and medical exam equipment I encounter. I receive a steady stream of compliments about my appearance. 

In the picture on the right, all of these things have stopped or changed significantly. I can only shop in one brick and mortar store – WalMart. I can either buy two seats on an airplane or risk being kicked off a flight. I can’t sit in the exit row. People are still generally civil to me, but mostly don’t smile unless I smile first, or as cover when I catch them staring at me. Doctors talk over me and write me off as non-compliant. I attend copiously-photographed events with hundreds of hash tagged photos and I am never in any of them. If I need an MRI I will have to call around and travel a considerable distance to find a machine that accommodates me at a facility my insurance will cover. People still say I have pretty eyes, but that’s about it. 

In the photo on the left, I have been eating one small meal per day for over six months. I think about food every waking moment and cry almost daily about food anxieties. I’m afraid to look at pictures of food or be anywhere near carbs of any kind. My hair has started falling out and my gums are tender and bleed easily. I am always cold, always tired, and always in a bad mood. The smile in the picture is fake; I am not enjoying my life. I walk around six blocks every morning and the exhaustion and muscle cramps make me cry. I still get fatcalled* on occasion by dudes driving by, and my anger fuels my determination to push way past my physical limits, but every step is miserable. I hate exercise, I am terrified of food, and while I don’t exactly hate my body (I have always been at least a little fat positive, I thought I was doing this for my health mostly), I’m immensely ashamed of it and frustrated by it. 

In the photo on the right, I am happy. I feel good physically. I go to the gym because I have energy to go to the gym, and I work out for the pleasure of moving my body and discovering its abilities. I think about food mainly when it’s time to eat or I’m planning a menu or a food-related event. I buy clothes I like instead of the ones that make me look the thinnest. I am not infatuated with my body – I don’t think it’s enchantingly beautiful or perfect and there are things I don’t like about how it looks – but I do love it. I respect it and try to listen to and nurture it. The smile on my face is genuine; I am not self-conscious in this picture, I’m thrilled to be with my friend who I rarely see, and happy to give her a picture to commemorate the visit. My gums are healthy, I’m not cold, and I’m (usually) reasonably cheerful. I have PCOS (a complex and progressive endocrine disorder), so my hair is sadly still thinning, but not falling out in patches anymore. 

Society says the picture on the left is better. Without question they would say that body is healthier. Doctors who knew exactly what I was eating and how I was exercising, and even some of my concerning symptoms, encouraged it. My behavior and symptoms could clearly be diagnosed as “atypical” anorexia (what they call anorexia when it does not present in medically underweight bodies, despite the fact that it is more prevalent than underweight anorexia), but it did not occur to anyone (least of all me) that I could have an eating disorder. Regardless of the truth of the actual health and well-being of the body on the left, the world around us makes room for that body, and a great many things in daily life are easier or more pleasant in that body because of that fact.

The body on the right is healthier, happier, more embodied and more empowered than the smaller one. The world does not make room for that body, but she makes room for herself. She stands up for herself and insists on respect and dignity, she fights for evidence-based and compassionate medical care, she understands that mental health is also health, that weight is not a shorthand for understanding a person’s individual health, let alone worthiness. And she does not apologize for taking up however much space she needs. 

My journey to recovery, intuitive eating, and genuine self-care illustrates the difference between self-esteem and structural oppression. The world prefers that smaller body and lets me know it at every turn. Me? The only thing I miss in that picture is those shoes. 

*”fatcalling” is like catcalling, only instead of (or on top of) sexual innuendo, it’s anti-fat slurs

Intuitive Eating Is For Every Body, But It Was Built On Fat Bodies

Intuitive Eating is for everyone. It is for me and for you, for all bodies, fat or thin. We all want, and we all need, peace with food and peace with our bodies, and the principles of Intuitive Eating are a tried and true method to achieve that peace. The very first principle of intuitive eating is to reject the diet mentality — the idea that thinness is achievable through controlling food and movement. Built into that process is the need to address one’s internalized fat-phobia and dismantle it. To quote The F*ck It Diet, “Our relationship with weight, and our deep fear of becoming fat ourselves, is one of the biggest causes of our dysfunction with food. Neutralizing the word fat, as well as the actual body type, is a really essential step in healing your relationship to food.” In other words, you cannot hold onto your fat phobia AND achieve peace with food and your body. It is not possible. Pointing out that you are struggling with this is not only a means of protecting the fat people around you from the demoralizing message that fat bodies are somehow ineligible for food freedom and body peace, it also helps you on your way toward the same goals. It is not an attack, it is an offer of support.

That said, I also need you to understand that your fear of fatness comes at my expense. When I say that, I don’t just mean that it makes me feel bad about myself. That, too, in my most vulnerable moments, but that is the smallest part of it. What I mean is that your perpetuating the pervasive idea that fatness is inherently bad makes it harder for fat people to access the self-esteem that you are grappling for when you make these fat-phobic comments. You only think you are fat, and when you express that fear, everyone will come to your rescue reassuring you the you are not, that you should not feel bad. Not only do fat people witness this and are forced to grapple with the implication that they therefore should feel bad, but, when n actually fat person expresses the same pain, nobody will come to their rescue with affirmations of who and what they are right now. They will be met with encouragement to change their bodies in order to qualify for access to that same affirmation that you receive automatically.

I also mean that bodies like mine have been unethically experimented on in the pursuit of evidence that our bodies are wrong, and those experimental interventions have caused harm to the individual fat bodies they were enacted upon as well as the fat bodies in society on whom those manipulated results have been foisted as “medically necessary” interventions. The conclusion that has mostly been reached – that diets don’t work after all and people just need to accept and care for whatever body they have – was paid for by fat bodies. The current insights into Health At Every Size and Intuitive Eating, which absolutely apply to fat and thin people alike, were built on the backs of fat bodies. It is fat bodies who were subjected to all of the failed interventions and attempts to solve the “problem” of fatness. Therefore, it is fat bodies that paved the way for you to access intuitive eating as a means to finding peace with your thin body’s imperfections*, and it adds insult to injury for small-bodied people to not only fail to recognize that history, but also attempt to silence fat people who point out that it is actually fat phobia that keeps you stuck in your process.

Fat people are not trying to silence thin people who are afraid of being fat. We are trying to tell you that when you constantly bring that fear up in mixed company without examining the underlying assumptions driving it or without acknowledging the implications for the actual fat bodies in the room, it hurts us, and that pain deserves acknowledgement also. We are trying to help you understand that being fat is only something to fear because of attitudes exactly like the one you are currently expressing, and that learning to let that go, and learning from people who understand exactly what being fat is about because they actually experience it, is the only way to help yourself and everyone witnessing and being impacted by your expressions of pain.

You cannot justly choose to access the supports and insights that were built by fat people – or thin people practicing on fat people – while simultaneously rejecting the insights of fat people. Intuitive eating is for everyone, but if not for fat phobia, there would be no need to relearn it, and if not for fat people, the insights that make this learning possible would not exist. If not for fat people (of color, for the record), body positivity would not exist as a cultural concept, and you would not feel half as liberated as you are already starting to feel if you are reading this blog.

The next time a fat person calls you to account for saying something fat phobic, instead of reacting, why not try reflecting? Why not sit with their response for a moment and consider it? Consider how learning to unravel the cords of fat-phobia that keep you tied to old habits that are not serving you could actually be the support you needed in that moment, even if you didn’t understand that. As a white person who has learned many lessons on racism from people who were not as gentle with my feelings as they were sure of my goodness, I can tell you, leaning into those hurt feelings is the best, most empowering way forward. For everyone.

* The notion of perfection/imperfection with respect to bodies is a false construct; bodies naturally have creases and folds, dimples and spots, lines and errant hairs, divots and bulges, and all manner of organic variety. The overwhelming majority of bodies do not look like the hairless, smooth, evenly-colored images in media. That is photoshop. So the idea that your body is imperfect because it doesn’t look like digitally-manipulated or extremely rare bodies seen in media is false.

No, You Do Not Feel Fat

Fat is not a feeling. It is an experience. Because I am actually fat, there is a long list of spaces and experiences I am limited or entirely excluded from, such as:

  • Buying clothing in most stores, or for comparable prices, as smaller people
  • Even finding fashionable or appropriate professional clothing at all
  • Trying on clothing before buying it
  • Sitting in chairs in many public spaces (if they have arms or are cheaply constructed)
  • Proper medical care and treatment due to missed or misdiagnoses stemming from weight bias and/or inaccessible medical equipment, or flat out refuse from medical providers or insurance companies to allow treatment at all
  • Job opportunities and/or advancement due to assumptions about my abilities and work ethic
  • Legal protection from the discrimination I am most likely to face
  • Dating prospects, due to internalized fat phobia and media saturation of one desirable body type which drives what people consider attractive and pushes me far out to the margins
  • Air travel, to some extent, since I can barely fit into the bathroom and can’t properly maneuver for hygiene purposes, and I could conceivably be forced off a flight I paid for and forced to pay for a second seat
  • Entertainment, like concerts, plays, and movies, where seating options don’t exist for my body
  • Fitness wear and equipment appropriate for my body (never mind attractive fitness clothing – finding any at all at any reasonable price)
  • Entertainment that does not use me as a punchline, a warning example, or inspiration porn. Entertainment that represents me with any dimensions at all beyond fatness.

This list is by no means exhaustive. There is another list, also. Things I experience that you, in your smaller body, are excluded from: 

  • Open harassment, sometimes even threats or acts of violence, in reaction to my body size by strangers in public and online
  • People taking pictures of my body to post and disparage on social media or in the actual news media
  • Unsolicited weight loss advice at any moment from any person at any time in any situation, regardless of the appropriateness of the timing or nature of our interaction. 
  • The stigma of being blamed for rising health care costs despite having none of the conditions driving it
  • Invasive questions about my personal health in situations where my personal health status is irrelevant
  • The stigma of my mere visual existence being considered a threat to the future health of all children. 
  • Additional medical costs and treatment delays due to medical bias against fat people and scapegoating of fatness for all medical issues
  • Seeing accomplishments of people like me diminished or discredited/discounted because they somehow “glorify obesity” by being fat and accomplishing things
  • Being disbelieved or ignored when I share my knowledge and experience on the topic of fat experience because I am fat and therefore am making excuses to continue existing instead of futilely pursuing thinness at considerable cost

That list is also not exhaustive, and not everything on either list applies to all objectively fat people. But both lists should serve to illustrate that being fat is not about how I see myself, it is about how society sees me – or chooses not to see me. My own feelings have very little to do with it. 

I understand that you experience bad body image even if you are thin. Frankly, I’m pretty sure you experience more bad body feelings than I do, mainly because I have been forced to constantly build myself up to keep facing the world every day as a fat person. So I get that there is real pain behind your words. But I need you to consider the pain that your words cause actual fat people.

When people who are not fat use that word to describe their negative emotions, it underscores the idea that if a person is actually fat then they deserve to feel bad about themselves, and to be treated as lesser. It legitimizes the association that our culture has made between my fat body and sadness, sickness, and death – despite the fact that these things come for all of us at some point, fat or thin. It contributes to the stereotypes that create the structural barriers that I actually face as a fat person; when people see my body as abnormal and undesirable, they create spaces and experiences that exclude my body. When people come to your rescue by reassuring you that you are not fat, they reinforce the idea that if you were fat, then your bad feelings would be appropriate.

Your fear of being fat comes at my expense. It doesn’t matter if you mean to hurt me when you say that, the fact is that you do. On an individual level, when I am in the room to hear you disparage the most noticeable characteristic of my body, and on a societal level, when other people hear you underscore the bias that keeps structural inequalities in place and continues to blame them on me.

Please, instead of thrashing blindly about in pain and harming others, consider using different words to describe your specific hurts. If you feel insecure, say that. If you feel sad, say that. If you feel lonely or scared or hungry or anxious, those are all wonderful words that apply to all of us and marginalize nobody. Fat is not a feeling, it is an experience. It is my body, and I need you to treat it with more respect. Thank you.

Dear Thin People,

I don’t hate you. It is important to say that now, because if you keep reading my blog, you might get the impression that I do. I promise, I do not. I have many nonfats in my life that I love dearly and would not change or trade for anything. I have many more nonfats in my life that I am not particularly close to but whose company I enjoy and whose mistakes and missteps I easily forgive because I make mistakes, too, and I hope they do the same. My general disposition toward individuals in all bodies is to expect good things but be prepared for disappointment. It’s a juggling act, but I have had lots of therapy – like, a lot – and I’m pretty good at it now.

So I don’t hate you. I don’t hate anyone. But I might call you out. I might criticize something you do, or fail to do, that causes harm to fat (and other marginalized) humans. Criticism is not hate. Criticism is feedback. If you value feedback from people who are experiencing the world in a way that you don’t understand, being okay with feedback that sometimes stings a little is necessary. It might even sting a lot. But my goal is to teach you. That is a labor of love. I love you, and I want you to be better, so I am making you uncomfortable so that you can grow.

I Am a Loud Fatty and I Break the Rules

Welcome to my blog. This is not my first blog, but maybe this one will outlast my penchant for abandoning hobbies. Probably not. I apologize in advance if I disappoint you. That will probably happen.

I break rules. like there is a rule that you have to capitalize the first word of a sentence and I broke it just to make my point. See? I am a rebel. I was probably born this way, but also, being fat made me this way. Rebellion is a survival skill. Anger is a tool.

I was raised in a fat family. We are sturdy, boisterous people. Fat is our unremarkable, it is our common bond. Our fat jokes make punchlines out of problems, not people. In my fat family, my roundness was safe. In my fat family, there was shelter from the fat hate outside. Families often cause each other pain, and mine is no exception, but my fat body was welcome in my house, no strings attached.

When I go outside or invite outside inside – through media, or just carrying conversations home in my mind – I am not always safe. There are those who actively wish me harm, but more insidious and ambiguous and therefore more dangerous, there are those who believe the harm they cause is my own fault, or for my own good.

This blog is the conversation I would have with those people if they would listen.