Combating Weight Stigma: A Call to Action for Health Professionals
“What I remember most from grade school is being teased about the way my legs jiggled when I ran. I hated that feeling.”
“I am constantly aware of how my body might look to other people. I’m constantly trying to look as thin as I can.”
“My doctor wouldn’t believe my symptoms were serious. He said ‘you’re too thin and fit to have diabetes.’”
“I got promoted after I lost 50 pounds; my boss told me I didn’t represent the company properly when I was overweight.”
“My 13-year-old daughter is starting to develop, and she is “overweight” according to her doctor; she is terrified of gaining any more. How do I help her see her body is not her enemy?”
What is Weight Stigma?
The above statements are the voice of weight stigma. Its power is immense – it can make people feel ashamed of themselves, interfere with their productivity, damage their health, and lead them to develop binge eating disorder (BED) and other eating disorders.
Even given the power it has, and all the forms it can take, the definition of “weight stigma” is simple: “Bullying, teasing, negative body language, harsh comments, discrimination or prejudice based on a person’s body size or weight.” (BEDA, 2010). Weight stigma depends upon three basic suppositions: thin is always preferable, thin is always possible, and thin people are better people. It is the belief in these underlying suppositions that make weight stigma a profound contributor to the toxic levels of shame that fuel BED and eating disorders in general. It is essential, therefore, that weight stigma be explored openly in clinical work with clients of all sizes.
The statistics tell some of the story of the scope of weight stigma:
- Weight discrimination occurs more frequently than gender or age discrimination (Puhl, Andreyeva, and Brownell, 2008).
- Weight discrimination has increased 66% in the last decade (Puhl 2009).
- Peer victimization can be directly predicted by weight (Grifﬁths, et. al, 2006).
- Obese youth who are victimized by their peers are 2-3x more likely to experience suicidal thoughts and behaviors than those who are not victimized.
The impact is additionally powerful because it is socially and culturally validated. There is typically little support in a client’s environment declaring weight stigma unacceptable. Indeed, most of us would find it strange to hear someone say they feel good about their body and its appearance. Further, it is supposed that any weight-related psychological damage happened principally through a client’s own fault. We know diets have a dismal success rate, especially over the long term. And yet, the notion that this is the fault of the individual is pervasive. For most clinicians however, our experience tells us this: it is principally the stigmatizing experience (because it induces shame), not simply the weight itself, which contributes to adverse outcomes, including eating disorders such as BED, long term weight cycling, and lower rates of recovery.
Adding to the impact, there are powerful forces invested in weight stigma. The weight loss industry is a $60 billion per year money maker, predicated on the notion that being thin is a valuable personal goal, somehow reflecting an internal strength of character. Given that permanent weight loss by diet is a near impossibility, this goal is one very rarely attained; it must be chased continually. While men and boys are an increasing target of this industry, women are still the principal audience. As Naomi Wolf asserts in The Beauty Myth (1991), “a culture fixated on female thinness is not an obsession about female beauty, [it is] an obsession about female obedience. Dieting is the most potent political sedative in women’s history; a quietly mad population is a tractable one.” Indeed, what might happen if suddenly women were encouraged to be at home in their bodies? Where might their energy go if our clients stopped chasing the fantasy of thin?
Who is Impacted by Weight Stigma? What is the Nature of the Impact?
Weight stigma happens everywhere. Simply leaving the house in a larger body can be an emotionally challenging experience for clients. Shopping for clothing, going to the beach, or eating a meal may all elicit public ridicule, and thereby anxiety and shame. In addition, weight stigma is especially likely to be internalized by those with BED and other eating disorders, many of whom are already impacted by toxic shame in other areas of their lives.
It is commonly believed that weight stigma is an issue only for girls and women, and only for those in bodies larger than our culture deems acceptable. In fact, weight stigma has a profound impact on us all. For those in more socially “acceptable” bodies, there is often a fear of weight gain, and of losing “thin privilege”. Increasingly, boys and men are being pressured to focus on weight and shape as well. Having “six pack” abs and muscle definition, in addition to being tall and trim, is becoming a highly reinforced cultural goal.
How Does Weight Stigma Affect Those with BED?
Weight stigma creates a place for the shame of BED and other eating disorders to take hold, and for the seduction of the “when I’m thin” fantasy. The yo-yo dieting cycle, and resulting self-blame for the inevitable “failure”, is often a core contributor to binge eating. Changing this pattern is fundamental to recovery.
Additionally, weight stigma creates problems in recognizing the severity of BED, and of receiving proper diagnosis and treatment. BED has been viewed as a problem of willpower, low self-esteem, or depression, and often not as a legitimate eating disorder. As a result, treatment, if offered at all, has been largely focused on weight loss. With 70% of those with BED considered “overweight” or “obese,” the number of people receiving only weight loss directives from their health care providers is considerable.
Research shows that a diagnosis of BED makes a person a target of more blame than other psychological disorders LaPorte, 1997; Mond & Hay, 2008; Wilson et al., 2009; Becker et al., 2010; Crisp, 2005; Mond et al., 2006; 2007. In a study of 1013 women who belonged to a national non-profit weight loss support organization, a profound connection between BED and weight stigma was noted. In this study, women who internalized experiences of weight stigma, and blamed themselves for this stigma, engaged in more frequent binge eating. This was true even after accounting for self-esteem, depression, and amount of stigma experienced (Puhl, 2007)
Working with Weith Stigma in the Treatment of BED: Some Important Considerations
It is imperative clinically to bear in mind that challenging weight stigma may be profoundly threatening for clients. Allowing for the possibility that one’s relationship with their body could be compassionate and tolerant brings the entire structure of the eating disorder into question. There is often significant loss when letting go of the fantasy of “thin”, and the belief that being “overweight” provides an explanation for attachment deficits and trauma. Additionally, weight stigma may fuel the fire of rebellion in a binge, provide a space for defiance by being “too big”, or allow a rejection of the expectations of others. In addition, weight stigma may allow the body to be experienced as a “keep out” barrier by clients unwilling to have intimate relationships due to prior betrayals and losses.
Ultimately, letting go of internalized weight stigma means feeling the feelings that powered the eating disorder and discovering if one really is acceptable in the world as they, and their body, truly are. Although everyone’s path is different, there are a few interventions commonly useful in the clinical milieu. They are:
- Honor the body as home
- Psychoeducation about weight, health, and dieting
- Address weight stigma-related trauma
- Increase client “embodiment”
- Cherish the “today body”
- Develop “weight stigma” eyes
The first, and perhaps most revolutionary, step is to help clients begin to understand their body as their “home.” It may begin with something Marsha Hudnall calls “body neutrality”. Body neutrality is “focusing on what your body does for you, or what you appreciate about your body, rather than what it looks like. Body neutrality acknowledges what is rather than longing for what isn’t.” (Beyond the Binge: A Woman’s Guide for Overcoming Emotional Overeating). It is in this process most of all we come to see that offering our body anything less than the best care is about external rules, internalized shame, or old messages. It is NOT about our body’s deservedness, no matter its size, shape, gender or age.
Second, as a clinician, learn the myths and facts about the relationship between health and weight. Much of the information we receive about weight and health does not prove causality, nor does it necessarily apply to any given person. We need to help clients pay attention to their body’s unique physical needs, and develop a relationship with food and movement that is based on immediate internal cues and desires, a general respect for nutrition, and an overall wisdom about their body’s responses to behavior. It is imperative to not focus on weight loss as a measure of recovery. Weight loss may happen or it may not. Helping clients come to terms with this reality is critical; in fact, it serves as a metaphor for the reclamation of all facets of the authentic Self in recovery. It is a significant part of our work to help clients find who they truly are, working to listen to that Self voice, and the body in which she or he lives.
Healing any traumatic experiences associated with weight stigma is also critical to recovery. This allows clients to externalize the blame for these traumas, and absolve their bodies of any responsibility for being targeted. Healing allows for tolerating increasing “embodiment”; that is, being aware of body needs, sensations and desires. A variety of interventions can be employed here, including mindful eating and movement strategies, affect tolerance, and breath work. Cherishing the “today body” involves both increased somatic awareness as well as working on internal body self talk. Weight stigma language can be subtle; clients need to be made aware of how to recognize and challenge these damaging distortions. CBT and DBT skills are helpful here.
Finally, both therapist and client must work on developing “weight stigma eyes”. We have a duty to ourselves and to our clients to consume images critically. If a message or an image makes us question our own body’s value, we need to back away. We must help clients do the same, and find resources that celebrate a variety of shapes and sizes.
Doing weight stigma work with clients in recovery is critical to long term healing and growth. To that end, therapists must lead the way, healing their relationships with their own bodies. The most profound skill-building tool we bring to clinical work is our own journey. Knowing our own journeys with weight stigma and body image is no exception.
Thank you for joining BEDA and taking part in Weight Stigma Awareness Week. We hope you will make use of the Weight Stigma Toolkits we are offering and participate in the opportunities for learning more about weight stigma over the coming days. Together, we can help our clients and ourselves create a more alive, joyful and validating environment for the bodies in which we live. Again, thank you for your participation and support!
Amy Pershing, LCSW, ACSW – 2013 Chair, BEDA