Archive for August, 2015

August 21, 2015

the HAES® files: When Prejudice Precludes Proper Healthcare

by Health At Every Size® Blog

by Ragen Chastain

When I was in college I had knee pain.  I was at the lowest weight of my adult life thanks to an as-yet undiagnosed eating disorder.  I went to the doctor and he gave me over a dozen options – had I considered massage or rolling it out on a rolling pin or baseball bat (these were the pre-foam roller and tiger stick days)?  He offered to prescribe physical therapy, saying that they could use ultrasound, ice, muscle manipulation and specific exercises to rehab the knee.  If all else failed we could look at surgery he said.

I did massage (ouch!), rolling on a baseball bat (double ouch!) and physical therapy and the knee got better.  It turned out that the problem wasn’t the knee itself but rather tightness of muscles and the IT band pulling on it.

Fast forward to a few years ago: after years of weight cycling my weight had finally stabilized thanks to my shift from a focus on body size and dieting to a focus on healthy behaviors.  I had the same knee pain that I’d had before, and this time I was one hundred pounds heavier than I had been during my ED days.  I headed to the doctor to get a prescription for physical therapy.  He told me the only thing that could possibly be done about my knee was weight loss.  I explained that I had this same pain at a much lower weight and that I would like to treat it the same way.  He said that there was “no point” in prescribing me physical therapy since I was “obviously too lazy” to do the exercises they would prescribe.  After finally talking him into prescribing the PT, he said that it “better work” since nobody would consider doing surgery on someone my size.

This is the healthcare that fatphobia has wrought.  A world where doctors feel free to stereotype fat patients. A world where thin people who go to the doctor get evidence-based options that are shown to solve their health problem, and fat people are diagnosed as fat and prescribed weight loss whether we have strep throat or are holding a severed limb (despite the stunning lack of evidence that it will lead to a smaller body or better health – which are, of course, two different things).

Doctors are subject to the same bigotry as anyone else, and in a society rife with racism, classism, homophobia, transphobia, ageism, sizeism and more, doctors’ personal prejudices can have a seriously detrimental effect on the ability of people in oppressed groups to get access to good evidence-based healthcare.  As a fat person we can see this in a number of ways.

Assumptions/Stereotypes 

The fat phobia of our culture – in which the government actively encourages everyone to see fat people as walking stereotypes – leads to doctors who feel confident putting more faith in their stereotypes of us than in what we actually tell them.  I can’t even count the number of times a doctor has told me to eat less and exercise more without having asked me how much I eat or exercise.  I once had a doctor tell me “I know it’s going to be hard, and you’re going to want to quit, but I need you to starting walking ten minutes a day.  I promise it will get easier.”  This was near the end of my training for my first marathon and I was regularly walking for 15 and 20 miles at a stretch.  When I told the doctor that, he said that if I didn’t want to do the walking I should just say so – not make up a story.

Lack of Evidence-Based Medicine and Informed Consent

When a doctor “prescribes” weight loss to me (which they have done when I presented with strep throat, a broken toe, and a separated shoulder) I always ask “Do you think that a recommendation of weight loss constitutes the ethical practice of evidence based medicine?”  They say “Yes.”  So I reply “Can you give me a study where participants lost the amount of weight that you are suggesting that I lose, maintained that weight loss long-term, and gained the health benefit you are saying it will have?” The answer ranges from “Everybody knows that you can lose weight if you try hard enough” to “I’m sure that there are studies.”

The answer is anything but the name of a study, because there isn’t one.  There isn’t a single study where more than a tiny fraction of people maintain weight loss long-term; in none of those studies was the weight loss more than a very small percentage of body weight (often 2-5 pounds); and, there isn’t a single study that has even attempted to prove that people who maintain weight loss receive health benefits.  This whole weight loss paradigm is based on guesses and bad science.  Thin people get all the same health problems that fat people do, and they aren’t prescribed weight loss. So why do they get evidence-based interactions and we get “try to manipulate your body size in a way that we have no reason to believe will make you thinner or healthier?”  That’s not evidence-based medicine. Doctors who fail to tell patients the truth about the research are also guilty of the ethics breach of failing to give the patient the opportunity for informed consent.

Refusing Treatment Based on Prejudice

A friend of mine was recently denied minimally invasive arthroscopic knee surgery by an orthopedic surgeon who claimed that her body size made the surgery too dangerous.  The surgeon gave my friend a referral to a bariatric surgeon.  So simple knee surgery with very few known side effects is too dangerous, but stomach amputation that often results in life-altering side effects and death is a great idea?

The idea that weight loss is a path to health is a Galileo issue – it’s widely believed, fervently supported, and it’s heresy to question it.  But “everybody knows” isn’t the same thing as “evidence-based.” If we are to give fat people access to good healthcare we must start by letting go of the idea that manipulation of body size is a health practice, and the mistaken belief that behaviors that supposedly promote weight loss are the same thing as behaviors that support health.  Healthcare providers must address their own prejudices and overcome them to see each patient as an individual who deserves ethical, evidence-based, compassionate care.

Leap credit Richard Sabel.JPGRagen Chastain is a trained researcher, three-time National Champion dancer, and marathoner who speaks and writes full-time about body image, health and wellness. Ragen has spoken at venues from Google Headquarters, to Darmouth and CalTech, to the We Are Girls conference. She is the author of the blogs DancesWithFat and IronFat, and the book Fat: The Owner’s Manual. She is the editor of The Politics of Size – Perspectives from the Fat Acceptance Movement, published by Praeger, and co-editor of the work in progress “Throwing Our Weight Around:  Real Stories of Fat People in the Fitness World.”

Ragen is a feature interviewee in the documentaries “America the Beautiful 2 – The Thin Commandments,” released by Warner Brothers,  “A Stage for Size” released by USC Films, and “Ragen’s More Cabaret” released by PBS, and a movie about her time as a fat competitive dancer is currently in active development. Ragen lives in Los Angeles with her partner Julianne and their adorable rescue dogs Bu and ChadShannel, and in her free time she is training for her second marathon and her first IRONMAN Triathlon.

(Photograph by Richard Sabel.)

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