Story spreads out through time the behaviors or bodies – the shapes – a self has been or will be, each replacing the one before. Hence a story has before and after, gain and loss. It goes somewhere…Moreover, shape or body is crucial, not incidental, to story. It carries story; it makes story visible; in a sense it is story. Shape (or visible body) is in space what story is in time. (Bynum, quoted in Garland Thomson, 113-114)
Drawing on Goffman’s classic work on stigma, research documenting the existence of discrimination and bias against individuals classified as obese goes back five decades. Since Cahnman published “The Stigma of Obesity” in 1968, other researchers have well documented systematic and growing discrimination against fat people (cf. Puhl and Brownell; Puhl and Heuer; Puhl and Heuer; Fikkan and Rothblum). While weight-based stereotyping has a long history (Chang and Christakis; McPhail; Schwartz), contemporary forms of anti-fat stigma and discrimination must be understood within a social and economic context of neoliberal healthism. By neoliberal healthism (see Crawford; Crawford; Metzel and Kirkland), I refer to the set of discourses that suggest that humans are rational, self-determining actors who independently make their own best choices and are thus responsible for their life chances and health outcomes. In such a context, good health becomes associated with proper selfhood, and there are material and social consequences for those who either unwell or perceived to be unwell.
While the greatest impacts of size-based discrimination are structural in nature, the interpersonal impacts are also significant. Because obesity is commonly represented (at least partially) as a matter of behavioral choices in public health, medicine, and media, to “remain fat” is to invite commentary from others that one is lacking in personal responsibility. Guthman suggests that this lack of empathy “also stems from the growing perception that obesity presents a social cost, made all the more tenable when the perception of health responsibility has been reversed from a welfare model” (1126). Because weight loss is commonly held to be a reasonable and feasible goal and yet is nearly impossible to maintain in practice (Kassierer and Angell; Mann et al.; Puhl and Heuer), fat people are “in effect, asked to do the impossible and then socially punished for failing” (Greenhalgh, 474).
In this article, I explore how weight-based stigma shaped the decisions of bariatric patients to undergo weight loss surgery. In doing so, I underline the work that emotion does in circulating anti-fat stigma and in creating categories of subjects along lines of health and responsibility. As well, I highlight how fat bodies are lived and negotiated in space and place. I then explore ways in which participants take up notions of time, specifically in regard to risk, in discussing what brought them to the decision to have bariatric surgery. I conclude by arguing that it is a dynamic interaction between the material, social, emotional, discursive, and the temporal that produces not only fat embodiment, but fat subjectivity “failed”, and serves as an impetus for seeking bariatric surgery.
This article is based on 30 semi-structured interviews with American bariatric patients. At the time of the interview, individuals were between six months and 12 years out from surgery. After obtaining Intuitional Review Board approval, recruitment occurred through a snowball sample. All interviews were audio-taped with permission and verbatim interview transcripts were analyzed by means of a thematic analysis using Dedoose (www.dedoose.com). All names given in this article are pseudonyms. This work is part of a larger project that includes two additional interviews with bariatric surgeons as well as participant-observation research.
Navigating Anti-Fat Stigma
In discussing what it was like to be fat, all but one of the individuals I interviewed discussed experiencing substantive size-based stigma and discrimination. Whether through overt comments, indirect remarks, dirty looks, open gawking, or being ignored and unrecognized, participants felt hurt, angry, and shamed by friends, family, coworkers, medical providers, and strangers on the street because of the size of their bodies. Several recalled being bullied and even physically assaulted by peers as children. Many described the experience of being fat or very fat as one of simultaneous hypervisibility and invisibility. One young woman, Kaia, said: “I absolutely was not treated like a person … . I was just like this object to people. Just this big, you know, thing. That’s how people treated me.”
Nearly all of my participants described being told repeatedly by others, including medical professionals, that their inability to lose weight was effectively a failure of the will. They found these comments to be particularly hurtful because, in fact, they had spent years, even decades, trying to lose weight only to gain the weight back plus more. Some providers and family members seemed to take up the idea that shame could be a motivating force in weight loss. However, as research by Lewis et al.; Puhl and Huerer; and Schafer and Ferraro has demonstrated, the effect this had was the opposite of what was intended. Specifically, a number of the individuals I spoke with delayed care and avoided health-facilitating behaviors, like exercising, because of the discrimination they had experienced. Instead, they turned to health-harming practices, like crash dieting. Moreover, the internalization of shame and blame served to lower a sense of self-worth for many participants. And despite having a strong sense that something outside of personal behavior explained their escalating body weights, they deeply internalized messages about responsibility and self-control. Danielle, for instance, remarked: “Why could the one thing I want the most be so impossible for me to maintain?”
It is important to highlight the work that emotion does in circulating such experiences of anti-fat stigma and discrimination. As Fraser et al have argued in their discussion on fat and emotion, the social, the emotional, and the corporeal cannot be separated. Drawing on Ahmed, they argue that strong emotions are neither interior psychological states that work between individuals nor societal states that impact individuals. Rather, emotions are constitutive of subjects and collectivities, (Ahmed; Fraser et al.). Negative emotions in particular, such as hate and fear, produce categories of people, by defining them as a common threat and, in the process, they also create categories of people who are deemed legitimate and those who are not. Thus following Fraser et al, it is possible to see that anti-fat hatred did more than just negatively impact the individuals I spoke with. Rather, it worked to produce, differentiate, and drive home categories of people along lines of health, weight, risk, responsibility, and worth. In this next section, I examine the ways in which anti-fat discrimination works at the interface of not only the discursive and the emotive, but the material as well.
Big Bodies, Small Spaces
When they discussed their previous lives as very fat people, all of the participants made reference to a social and built environment mismatch, or in Garland Thomson’s terms, a “misfit”. A misfit occurs “when the environment does not sustain the shape and function of the body that enters it” (594). Whereas the built environment offers a fit for the majority of bodies, Garland Thomson continues, it also creates misfits for minority forms of embodiment. While Garland Thomson’s analysis is particular to disability, I argue that it extends to fat embodiment as well.
In discussing what it was like to navigate the world as fat, participants described both the physical and emotional pain entailed in living in bodies that did not fit and frequently discussed the ways in which leaving the house was always a potential, anxiety-filled problem. Whereas all of the participants I interviewed discussed such misfitting, it was notable that participants in the Greater New York City area (70% of the sample) spoke about this topic at length. Specifically, they made frequent and explicit mentions of the particular interface between their fat bodies and the Metropolitan Transit Authority (MTA), and the tightly packed spaces of the city itself.
Greater New York City area participants frequently spoke of the shame and physical discomfort in having to stand on public transportation for fear that they would be openly disparaged for “taking up too much room.” Some mentioned that transit seats were made of molded plastic, indicating by design the amount of space a body should occupy. Because they knew they would require more space than what was allotted, these participants only took seats after calculating how crowded the subway or train car was and how crowded it would likely become. Notably, the decision to not take a seat was one that was made at a cost for some of the larger individuals who experienced joint pain.
Many participants stated that the densely populated nature of New York City made navigating daily life very challenging. In Talia’s words, “More people, more obstacles, less space.” Participants described always having to be on guard, looking for the next obstacle. As Candice put it: “I would walk in some place and say, ‘Will I be able to fit? Will I be able to manoeuvre around these people and not bump into them?’ I was always self-conscious.”
Although participants often found creative solutions to navigating the hostile environment of both the MTA and the city at large, they also identified an increasing sense of isolation that resulted from the physical discomfort and embarrassment of not fitting in. For instance, Talia rarely joined her partner and their friends on outings to movies or the theater because the seats were too tight. Similarly, Decenia would make excuses to her husband in order to avoid social situations outside of the home: “I’d say to my husband, ‘I don’t feel well, you go.’ But you know what? It was because I was afraid not to fit, you know?”
The anticipatory scrutinizing described by these participants, and the anxieties it produced, echoes Kirkland’s contention that fat individuals use the technique of ‘scanning’ in order to navigate and manage hostile social and built environments. Scanning, she states, involves both literally rapidly looking over situations and places to determine accessibility, as well as a learned assessment and observation technique that allows fat people to anticipate how they will be received in new situations and new places.
For my participants, worries about not fitting were more than just internal calculation. Rather, others made all too clear that fat bodies are not welcome. Nina recalled nasty looks she received from other subway riders when she attempted to sit down. Decenia described an experience on a crowded commuter train in which the woman next to her openly expressed annoyance and disgust that their thighs were touching. Talia recalled being aggressively handed a weight loss brochure by a fellow passenger.
When asked to contrast their experiences living in New York City with having travelled or lived elsewhere, participants almost universally described the New York as a more difficult place to live for fat people. However, the experiences of three of the Latinas that I interviewed troubled this narrative. Katrina felt that the harassment she received in her country of origin, the Dominican Republic, was far worse than what she now experienced in the New York Metropolitan Area. Although Decenia detailed painful experiences of anti-fat stigma in New York City, she nevertheless described her life as relatively “easy” compared to what it was like in her home country of Brazil. And Denisa contrasted her neighbourhood of East Harlem with other parts of Manhattan: “In Harlem it's different. Everybody is really fat or plump – so you feel a bit more comfortable. Not everybody, but there's a mix. Downtown – there's no mix.” Collectively, their stories serve as a reminder (see Franko et al.; Grabe and Hyde) to be suspicious of over determined accounts that “Latino culture” is (or people of colour communities in general are), more accepting of larger bodies and more resistant to weight-based stigma and discrimination.
Their comments also reflect arguments made by Colls, Grosz, and Garland Thomson, who have all pointed to the contingent nature between space and bodies. Colls argue that sizing is both a material and an emotional process – what size we take ourselves to be shifts in different physical and emotional contexts. Grosz suggests that there is a “mutually constitutive relationship between bodies and cities” – one that, I would add, is raced, classed, and gendered. Garland Thomson has described the relationship between bodies and space/place as “a dynamic encounter between world and flesh.” These encounters, she states, are always contingent and situated: “When the spatial and temporal context shifts, so does the fit, and with it meanings and consequences” (592). In this sense, fat is materialized differently in different contexts and in different scales – nation, state, city, neighbourhood – and the materialization of fatness is always entangled with raced, classed, and gendered social and political-economic relations.
Nevertheless, it is possible to draw some structural commonalities between divergent parts of the Greater New York City Metropolitan Area. Specifically, a dense population, cramped physical spaces, inaccessible transportation and transportation funding cuts, social norms of fast paced life, and elite, raced, classed, and gendered norms of status and beauty work to materialize fatness in such a way that a ‘misfit’ is often the result for fat people who live and/or work in this area. And importantly, misfitting, as Garland Thomson argues, has consequences: it literally “casts out” when the “shape and function of … bodies comes into conflict with the shape and stuff of the built world” (594). This casting out produces some bodies as irrelevant to social and economic life, resulting in segregation and isolation. To misfit, she argues, is to be denied full citizenship.
Responsibilising the Present
Garland Thomson, discussing Bynum’s statement that “shape carries story”, argues the following: “the idea that shape carries story suggests … that material bodies are not only in the spaces of the world but that they are entwined with temporality as well” (596). In this section, I discuss how participants described their decisions to get weight loss surgery by making references to the need take responsibility for health now, in the present, in order to avoid further and future morbidity and mortality. Following Adams et al., I look at how the fat body is lived in a state of constant anticipation – “thinking and living toward the future” (246).
All of the participants I spoke with described long histories of weight cycling. While many managed to lose weight, none were able to maintain this weight loss in the long term – a reality consistent with the medical fact that dieting does not produce durable results (Kassirer and Angell; Mann et al.; Puhl and Heuer). They experienced this inability as not only distressing, but terrifying, as they repeatedly regained the lost weight plus more. When participants discussed their decisions to have surgery, they highlighted concerns about weight related comorbidities and mobility limitations in their explanations. Consistent then with Boero, Lopez, and Wadden et al., the participants I spoke with did not seek out surgery in hopes of finding a permanent way to become thin, but rather a permanent way to become healthy and normal. Concerns about what is considered to be normative health, more than simply concerns about what is held to be an appropriate appearance, motivated their decisions.
Significantly, for these participants the decision to have bariatric surgery was based on concerns about future morbidity (and mortality) at least as much, if not more so, than on concerns about a current state of ill health and impairment. Some individuals I spoke with were unquestionably suffering from multiple chronic and even life threatening illnesses and feared they would prematurely die from these conditions. Other participants, however, made the decision to have bariatric surgery despite the fact that they had no comorbidities whatsoever. Motivating their decisions was the fear that they would eventually develop them.
Importantly, medial providers explicitly and repeatedly told all of these participants that lest they take drastic and immediate action, they would die. For example: Faith’s reproductive endocrinologist said: “you’re going to have diabetes by the time you’re 30; you’re going to have a stroke by the time you’re 40. And I can only hope that you can recover enough from your stroke that you’ll be able to take care of your family.” Several female participants were warned that without losing weight, they would either never become pregnant or they would die in childbirth. By contrast, participants stated that their bariatric surgeons were the first providers they had encountered to both assert that obesity was a medical condition outside of their control and to offer them a solution. Within an atmosphere in which obesity is held to be largely or entirely the result of behavioural choices, the bariatric profession thus positions itself as unique by offering both understanding and what it claims to be a durable treatment.
Importantly, it would be a mistake to conclude that some bariatric patients needed surgery while others choose it for the wrong reasons. Regardless of their states of health at the time they made the decision to have surgery, the concerns that drove these patients to seek out these procedures were experienced as very real. Whether or not these concerns would have materialized as actual health conditions is unknown. Furthermore, bariatric patients should not be seen as having been duped or suffering from ‘false consciousness.’ Rather, they operate within a particular set of social, cultural, and political-economic conditions that suggest that good citizenship requires risk avoidance and personal health management. As these individuals experienced, there are material and social consequences for ‘failing’ to obtain normative conceptualizations of health. This set of conditions helps to produce a bariatric patient population that includes both those who were contending with serious health concerns and those who feared they would develop them. All bariatric patients operate within this set of conditions (as do medical providers) and make decisions regarding health (current, future, or both) by using the resources available to them.
In her work on the temporalities of dieting, Coleman argues that rather than seeing dieting as a linear and progressive event, we might think of it instead a process that brings the future into the present as potential. Adams et al suggest concerns about potential futures, particularly in regard to health, are a defining characteristic of our time. They state: “The present is governed, at almost every scale, as if the future is what matters most. Anticipatory modes enable the production of possible futures that are lived and felt as inevitable in the present, rendering hope and fear as important political vectors” (249). The ability to act in the present based on potential future risks, they argue, has become a moral imperative and a marker of proper of citizenship. Importantly, however, our work to secure the ‘best possible future’ is never fully assured, as risks are constantly changing. The future is thus always uncertain. Acting responsibly in the present therefore requires “alertness and vigilance as normative affective states” (254).
Importantly, these anticipations are not diagnostic, but productive. As Adams et al state, “the future arrives already formed in the present, as if the emergency has already happened…a ‘sense’ of the simultaneous uncertainty and inevitability of the future, usually manifest in entanglements of fear and hope” (250). It is in this light, then, that we might see the decision to have bariatric surgery. For these participants, their future weight-related morbidity and mortality had already arrived in the present and thus they felt they needed to act responsibly now, by undergoing what they had been told was the only durable medical intervention for obesity. The emotions of hope, fear, anxiety and I would suggest, hatred, were key in making these decisions.
Medical, public health, and media discourses frame obesity as an epidemic that threatens to bring untold financial disaster and escalating rates of morbidity and mortality upon the nation state and the world at large. As Fraser et al argue, strong emotions (such hatred, fear, anxiety, and hope), are at the centre of these discourses; they construct, circulate, and proliferate them. Moreover, they create categories of people who are deemed legitimate and categories of others who are not. In this context, the participants I spoke with were caught between a desire to have fatness understood as a medical condition needing intervention; the anti-fat attitudes of others, including providers, which held that obesity was a failure of the will and nothing more; their own internalization of these messages of personal responsibility for proper behavioural choices, and, the biologically intractable nature of fatness wherein dieting not only fails to reduce weight in the vast majority of cases but results, in the long term, in increased weight gain (Kassirer and Angell; Mann et al.; Puhl and Heuer). Widespread anxiety and embarrassment over and fear and hatred of fatness was something that the individuals I interviewed experienced directly and which signalled to them that they were less than human. Their desire for weight loss, therefore was partially a desire to become ‘normal.’
In Butler’s term, it was the desire for a ‘liveable life. ’A liveable life, for these participants, included a desire for a seamless fit with the built environment. The individuals I spoke with were never more ashamed of their fatness than when they experienced a ‘misfit’, in Garland Thomson’s terms, between their bodies and the material world. Moreover, feelings of shame over this disjuncture worked in tandem with a deeply felt, pressing sense that something must be done in the present to secure a better health future. The belief that bariatric surgery might finally provide a durable answer to obesity served as a strong motivating factor in their decisions to undergo bariatric surgery. By taking drastic action to lose weight, participants hoped to contest stigmatizing beliefs that their fat bodies reflected pathological interiors. Moreover, they sought to demonstrate responsibility and thus secure proper subjectivities and citizenship. In this sense, concerns, anxieties, and fears about health cannot be disentangled from the experience of anti-fat stigma and discrimination. Again, anti-fat bias, for these participants, was more than discursive: it operated through the circulation of emotion and was experienced in a very material sense. The decision to have weight loss surgery can thus be seen as occurring at the interface of emotion, flesh, space, place, and time, and in ways that are fundamentally shaped by the broader social context of neoliberal healthism.
I am grateful to the anonymous reviewers of this article for their helpful feedback on earlier version.
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