the HAES® files: A Different Kind of Understanding

by Health At Every Size® Blog

by Fall Ferguson, JD, MA

Next week is Weight Stigma Awareness Week. As I pondered what to write about that, I found myself getting irritated that we need an awareness week. (Perhaps a recent viewing of Morgan Freeman schooling Mike Wallace on Black History Month was influencing me.)

The problem of weight stigma is well-described in the literature. Why are so many health and wellness professionals and policy makers oblivious to the harm caused by weight stigma? Stigma and bias are generally understood to be social determinants of health. What would it take for size to be included as a source of health inequities, just as race, ethnicity, gender, sexual identity, age, socioeconomic status, and geographic location currently are?

Starting with an assumption that most health and wellness professionals and policy makers think they are doing the right thing by emphasizing weight, how do we persuade these do-gooders that they are not, in fact, doing good? The short answer is, the research is necessary, but it’s not enough. We need to foster a different kind of understanding.

Sailors, Prostitutes, and Circus Sideshow People

seeing patients coverIn Seeing Patients: Unconscious Bias in Healthcare, African-American physician and Harvard medical professor Augustus A. White III, MD recounts his journey to understanding the impact of bias and stigma. White broke through many barriers to succeed in his profession and was familiar with the literature on health disparities, yet the role that stigma and bias play in health outcomes was not immediately apparent to him until “one event in particular triggered a different kind of understanding for me” (p. 195).

The event? During an airplane journey in the late 1990s, he sat next to an attractive, “normal” young woman who revealed that she was a tattoo model whose body was (other than her face and hands) 100% covered with tattoos. He recalled a medical school lecture in which slides of tattooed bodies were presented as belonging to “sailors, prostitutes, and circus sideshow people,” as well as convicted criminals. Dr. White noted that the lecturer had clearly conveyed that heavily tattooed people were “[n]ot really up to the level of normal people—like those of us in the lecture hall” (p. 196). His inability to reconcile his perceptions of his seat companion with the perspective he had learned in medical school has a name: cognitive dissonance.

Because They Treat Me So Badly

The young woman then revealed she hated to go to doctors “[b]ecause they treat me so badly.” Dr. White immediately understood: “I pictured her sitting in a doctor’s office unclothed for an examination. I could just see the stares, the amazement, the intrusive questions, the doctor maybe inviting one or two others in to take a look. … And how would this doctor treat her? … He would almost assuredly approach her with something other than simple objectivity and compassion for whatever it was that was troubling her” (p. 196).

Dr. White’s cognitive dissonance cracked open his understanding and allowed him to link data about health disparities with a deeper awareness of how stigma affects the doctor-patient encounter:

I had actually seen that kind of thing more than once. Not with tattooed people, but with obese people and elderly people. I knew doctors who did not relate to these patients as they should have, who were a little put off or impatient, who weren’t as attentive as they would have been with someone more supposedly “normal.” …

That night I was thinking over my talk with the tattooed young woman and suddenly something clicked … this girl was “other.” [In comparison with patients who are “other” racially, ethnically, or culturally “other” she] was the same as they were, “other” in a way that would inevitably trigger reactions from doctors that were neither sympathetic nor especially compassionate. And those visceral reactions were very likely to affect the medical care they provided. They might be a little less engaged, a little more rushed. They might be more likely to allow stereotypes to enter into their judgments. You didn’t have to be an overt racist or bigot of some sort for this to happen. … It would be enough to have feelings of distaste or discomfort, even feelings you might not acknowledge to yourself, or maybe weren’t even explicitly aware of. “(p. 197)

This event brought about what Dr. White describes as a “revelation” about the detrimental effects of even subtle biases. He went on to spearhead the infusion of cultural competency training into the curriculum at Harvard Medical School, no doubt influencing medical school curricula everywhere.

Transformative Learning Requires Cognitive Dissonance

Transformative learning theory concerns how adults can change their frames of references, such as beliefs, assumptions, preconceptions, and perspectives. From the educator’s perspective, it’s about creating the conditions for the learner to undergo an authentic and lasting transformation of some kind. Significantly, the first three steps of the transformative learning process involve disorientation, emotional reaction to the new information, and examination of assumptions. In essence, it’s the deliberate introduction of cognitive dissonance for the purpose of facilitating transformation. You can see this process reflected in Dr. White’s account of his “revelation” experience.

In a recent TED Talk, Peter Attia, MD recounted how his own experience of cognitive dissonance led him to rethink his perspectives on “obesity.” He described judging a patient in the ER where he worked because she was a fat woman with diabetes; he saw her as at fault for her poor health. He subsequently gained weight “despite doing everything right,” and was diagnosed with metabolic syndrome (which includes insulin resistance and is regarded as a precursor to diabetes). The disconnect between what the medical profession (of which he was a part) said about fatness and blood sugar and his own lived reality caused him to reexamine his entire paradigm around the etiology and treatment of diabetes. Dr. Attia ended his talk with an apology to the woman in the ER:

I’d like to tell her how sorry I am. I’d say as a doctor I did the best with the clinical care I could, but as a human being, I let you down. You didn’t need my judgment and my contempt. You needed my empathy and compassion. And above all else you needed a doctor who was willing to consider, maybe you didn’t let the system down. Maybe the system, of which I was a part, was letting you down. If you’re watching this now, I hope you can forgive me.”

To “achieve health equity, eliminate disparities, and improve the health of all groups” is one of the four “overarching goals” of U.S. national public health strategy. That health inequities need to be eliminated is not up for debate. The challenge is to add weight stigma and size bias to the list of social determinants of health that people consider when developing programs and campaigns to address health inequities, whether the setting is medical and allied health treatment, public health initiatives, school policies, or community wellness campaigns. Some constructive cognitive dissonance in the form of the human face of weight stigma is called for. We need to crack open their understanding and make room for the humanity.

Recall Dr. White’s “different kind of understanding” brought about by coming into contact with a new perspective that brought the human face of the “other” to his awareness. We need to make the voices of all people treated badly or judged because of their size or weight—large, small, thin, fat—audible to folks who ordinarily can’t hear them. The stories, the anguish, and the shame need to be heard.

I am very proud that ASDAH is already working on the Resolved video project (with assistance from the Size Diversity Task Force). The video is designed to educate health care practitioners and will center on the voices of patients who have been subjected to size bias. We unveiled the trailer at our recent conference, and everyone who has seen it has been powerfully affected. Now filming is almost complete, and we are launching a campaign to raise the funds to complete the editing and other post-production activities. I hope readers will watch the trailer and consider donating to our GoFundMe campaign.

7 Responses to “the HAES® files: A Different Kind of Understanding”

  1. Great article. The problem is that so long as people (including health care providers) believe that we “did this to ourselves” by “making bad choices” they are going to treat us as though we did this to ourselves by making bad choices. What worse, when they tell us to “stop making the bad choices” that “made us fat in the first place” and we don’t become thin upon hearing their words of wisdom, they then view us as “argumentative”, “unwilling to take their advice”, “untruthful” and “non-compliant.”

    I can’t tell you how many health care providers over the decades have told me that I need to give up candies, sweets and desserts – even though for the most part I don’t, and never have, eaten or even wanted to eat those kinds of foods. (I do eat birthday cake occasionally at a friend’s birthday party – mostly to be polite and not be a kill-joy – not because I actually like the stuff.) I am, and always have been, a person who loves a good salad or some fresh veggies or a yummy soup or stew FAR more than some sugary treat … but my body is like an inescapable Scarlet Letter that (falsely) screams out to every person I meet, “She’s lying! She’s lying! Just LOOK at her and you can TELL she’s lying!”

    That is MY “cognitive dissonance.” I’m the only person in the world who knows I am not lying about what and how much I actually eat, or about what I LIKE to eat. Everyone else thinks I’m lying and “in denial” and believes they can tell I’m lying and in denial just by looking at my body size. And THAT cognitive dissonance is the kind of long-time life experience that can make a person totally crazy.

  2. Good points rg. What you have said and this article reminds me of one of the best and worst experiences of my life, which was visiting the Holocaust Museum in LA. Best because it was powerful, worst because I was a teenager and saw something that not only hurt me but affected my outlook on life.

    In one room there is a presentation on stereotypes, and how we cannot judge others by looks. Negative stereotypes are attached to so many other groups, but for fat people, the stereotype was “jolly.” You can’t assume all fat people are jolly is what it said, never mind the fact that nobody assumes fat people in general are jolly. Maybe small children when dealing with a portly, white haired man with a beard (ie, because they believe he’s Santa), but the rest of society does not believe fat people are “jolly.”

    It has frustrated me for the last decade and a half seeing real stereotypes and assumptions go unchallenged (fat people all eat too much sweets/fast food/soda/eat too much in general) while others which can only down play how stigmatized we really are are passed on (like the jolly thing… I would love for people to assume that I am jolly, but I know the assumption is I’m stupid, lazy, and eat bad foods and don’t care about myself). No matter how many times I see sociological studies in regards to weight, stigma, and other related social factors, like income or access to healthy foods, no headway is ever going to be made until the mainstream media picks up these articles, instead of continuously running stories on how fat kills, or causes depression, etc.

    • Those are very good points about the media. Health care providers receive maybe, what? ONE class, ONCE (at BEST) about nutrition and obesity. But they, like the rest of us, hear every single day, day after day, every single time they turn on the news or read a newspaper some prettied-up version of, “fat people all eat too much sweets/fast food/soda/eat too much in general” along with “stories on how fat kills, or causes depression, etc.” along with hundreds of ads, contests, etc. that give the impression that there are literally hundreds if not thousands of ways to lose significant amounts of weight and the only thing preventing it is that the fat person “doesn’t want it badly enough.”

    • Museum of Tolerance that is. Looked it up to double check my facts.

  3. Terrific blog, and something I can use with other people with varying degrees of HAES and FA acceptance. Yay!

  4. I can identify with Dr. Attia. No matter how long I live, as the years go by, I keep catching myself judging people by stereotypes, despite my perception of myself as “liberal” and “open-minded”, disinclined to judge others unless I have walked in their moccasins. I condemn others for stigmatizing fat people and judging them unfairly, yet I find myself doing the same thing to other groups from time to time–and I see friends doing the same. Maybe we are hard-wired to want to feel superior to someone. The best answer to all this is to learn real humility, to accept differences in others, and to simply “judge not, lest ye be judged.”


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