BEDA promotes cultural acceptance of, and respect for, the natural diversity of sizes, as well as promoting a goal of improved health, which may or may not include weight change. The views expressed by our featured bloggers are their own.
Angela Meadows, MSc is the founder of Never Diet Again UK, delivering HAES® workshops to women with a history of weight, food and body image issues. A biomedical scientist by training, she qualified as a personal trainer and completed an MSc in weight management before she realized that the dieting was the problem, not the solution. As well as being a HAES and size acceptance activist, she is currently studying for a doctorate looking at size acceptance and internalized weight stigma.
Weight Bias, Weight Stigma and Body Work Professionals
Fat bodies. We are taught from an early age that we should hate and fear them. Be repulsed by our tummies, our cellulite, our hips, our thighs, our very flesh. And we learn this lesson well. Many of us dissociate our being from what we see as no more than a repugnant ‘external shell’ – we no longer even consider our bodies to be a part of us. Our body is a thing. An alien other. Never to be treated with love or respect. Not something to be honored or cared for. Something to be despised. To be destroyed. And it should not come as a surprise that people who feel this way about their bodies are unlikely to treat them well. To nourish them. To move them.
Professionals who work with fat people and their bodies are perhaps ideally situated to finally repair the shattered relationships that so many of us have with our fat bodies. People like physical therapists, fitness professionals, and massage therapists, for whom embodiment is their stock in trade. What’s more, bodywork professionals generally do what they do because they care about bodies, and the people inside them.
By official reckoning, fat people make up about two-thirds of our populace. You’d think this would mean that professionals who provide such services would be well versed in working with them. But while we are apparently becoming fatter, weight stigma is nevertheless on the rise. Arguments that more exposure to fat bodies in society will make us more accepting of them have not been borne out. And just like everyone else, bodywork professionals are a product of their environment. They may see more fat people coming through their door, but sadly, they are not necessarily any better disposed towards them than the rest of society.
The scientific literature is strongest for the prevalence and effects of weight stigma amongst sport and exercise professionals. The rot seems to start early. In-depth interviews with adults about their recollections of school physical education suggest that on the whole “fat phobia created extremely difficult situations that demanded constant psychic/emotional work, provided pitiful opportunities for learning, and numerous alienating and traumatic movement experiences.” More recently, interview studies with ‘overweight’ adolescents have shown that the vast majority experience weight related name-calling and bullying at all stages of the physical education environment, from the locker room, during team sports, and even when sitting out injured. Teens reported being called names like “earthquake”, “tubbo”, and “fat ape girl”, having their skill levels mocked, and being laughed at if they fell. Even more shockingly, teachers were present in over half of these occurrences and often ignored them, laughed at the teasing, or advised the victims to just ignore the bullies. In a study of 162 physical educators, teachers were found to possess more negative attitudes towards ‘overweight’ students than to their lighter peers, expect them to be less fit and healthy, and to have lower performance expectations for them. Similar findings have been shown in adult fitness professionals and in exercise science students. Worryingly, a 2007 study that compared 180 PE students with 164 matched psychology students at the start of their 1st year and towards the end of their 3rd year of university, found that both had similar levels of dislike for fat people at the start of their education, but that this had increased noticeably for the PE students after nearly three years of training. Looking at the students’ implicit attitudes – the ones they hold subconsciously, by their 3rd year, the PE majors had learned that fat people were even more lazy and stupid than they had originally thought, and their overall negative impressions had increased by about a third since their first year.
These negative assumptions and stereotypical beliefs may well become a self-fulfilling prophecy, with negative expectations being translated into lower self-efficacy and less engagement in physical activity. Both fat children and adults quickly learn that exercise and fitness is not for people who look like them, except as a form of penance. A small study published in the Journal of Teaching in Physical Education found that high school students whose BMI put them in the top 15th percentile for their age had been traumatized to the point of learned helplessness by their previous experiences of physical education and now avoided participation. Critically, these students were apparently more concerned about their visibility – exercising while fat – than they were about their performance. The potential solution offered by the authors, that these students might then engage in physical activity if they were shielded from their peers, for example, in fat-only classes – is more indicative of the problem than of a solution. And by adulthood, higher BMI is associated with more internalised weight stigma, less self-perceived physical competency, reduced motivation to exercise, and lower engagement in physical activity, and when they do take part in fitness activities, heavier women report less enjoyment and lower post-exercise energy levels than their thinner peers.
Another study looked at subconscious attitudes of fitness center employees and found that although they didn’t think they were biased, their subconscious negative feelings towards their heavier clients were not reduced even when seeing fat people actually engaged in exercise. Some gyms mock fat people in their advertising, and it’s not unusual for class instructors to openly stigmatizing fat bodies and use them as a cautionary tale, encouraging participants to work harder to alleviate or prevent such a fate befalling them. Is this really what you want for your clients? Is this really how you serve them?
In contrast, little has been written in the research literature about weight stigma in physical therapy or holistic treatment settings. Anecdotally, we hear stories of people refused treatment because of their size, like the case of 250 lb runner Laura Smith, who was turned away from a Colorado business for being too large. She was told that she might break the table and would then have to pay for it. She left in tears. The owner of the business denies being rude to Smith, but says she was just concerned for her wellbeing, as they had recently had a table break under the weight of a 165 lb man. As standard working weights for massage tables are around 450 lbs, and the ones at this clinic were designed to bear 500 lbs, one can only wonder about what was going on there.
Researching this blog, I did find a few posts from students or newly qualified therapists, asking for advice about working with heavier clients. The responses were usually helpful, compassionate, and all about making the experience as good for the client as possible. Any hints of anti-fat bias, such as this one where the practitioner wanted to charge more for heavier people because they were ‘more work’ and required ‘advanced training’(!) were generally challenged, and the questioners reminded that they were supposed to be in the caring and healing business and discrimination isn’t nice. Or legal.
Part of the issue is that societal anti-fat bias means some people still consider the issue of fatness to be a bit of a taboo subject. Liz Prato, writing in Massage & Bodywork Magazine, notes that most massage schools prepare their students for working with a wide range of ‘special populations’ – clients that may require specialist knowledge or additional skills – older clients, infants, pregnant women, people with cancer and so on. But it is still rare to find a class on working with fatter clients, despite our prevalence in the population. And some schools continue to spread misinformation about the universally sedentary unhealthy lifestyles that all fat people apparently engage in, resulting in them all suffering from self-inflicted chronic diseases, which of course puts the therapist in a position to deign to help all these stupid, lazy, sick fat people. And they continue to treat weight as something shameful, not to be mentioned for fear of embarrassing patients (and therapist), and advise practitioners to make all needed adjustments but not to mention the elephant in the room, as it were. These people know they’re fat. Most would be delighted by the realization that their therapist is doing everything they can to make them more comfortable and tailor the session to them, without judgment. I can’t imagine a college giving the same advice to therapists having to deal with, for example, very tall patients: ‘Yes, make adjustments, but whatever you do, don’t mention their height!!’ Our bodies are what they are, and this sanctimonious approach perpetuates fat-shaming attitudes and helps neither client nor therapist.
Plus-sized herself, Mara Nesbitt-Aldrich worked as a licensed massage therapist for 30 years, and made a special effort to cater to other women of size. She says, “When I was doing massages on fat women, they’d sometimes tell me about previous massages they’d had. One woman told me that her former therapist would only massage the middle third of her body. This way the therapist wouldn’t have to touch her folds or crevasses, and I’ve had similar experiences myself.” Nesbitt-Aldrich also reports hearing of therapists who tell patients they need to lose weight, and take it upon themselves to ‘educate’ them how they should be doing that. “That is not what people want when they go for a massage,” she states.
But on the whole, while prejudice and discrimination towards both fat clients and fat therapists it is far more common to hear positive experiences of massage. Possibly more than any other healthcare provider, massage therapists see what bodies really look like, in all their saggy, dimpled glory.