How weight bias affects the quality of healthcare given to women

Gina Tonic
·10-min read
Photo credit: Getty Images
Photo credit: Getty Images

From Cosmopolitan

In my final year of university, weighing in at around 15 stone at five foot, six inches tall, and with an obese BMI of 33.89, I approached my GP to ask for a repeat prescription of the Yasmin pill - the contraceptive with some of the highest levels of female hormones. I had been using Yasmin as a treatment for my PCOS symptoms such as hair growth (in particular facially), missed periods and weight gain. I relayed this to my doctor: “I want the pill so I can stop the weight gain, my lack of menstruation and my newly found beard.”

The doctor’s response was patronising. “Actually, the pill doesn’t make you gain weight, that’s a misconception made by many women,” he insisted. “The pill simply makes your appetite stronger.” The answer infuriated me for two reasons: First, I’d explicitly said the pill would be to help stop my weight gain - as it had achieved for me in the past - not that it would make me gain weight. Secondly, the air of condescension about women’s (and my own) contraceptive knowledge in general. My GP hadn’t listened to my question because he had already made his mind up upon viewing me: I was not a suitable candidate for the pill.

Yasmin (and other contraceptive pills with high hormone levels) puts plus size patients at a high risk of blood clots, as well as other issues. The only option to help with my PCOS problems, my doctor told me, was weight loss. As an eating disorder sufferer living with a condition that directly impedes my ability to lose weight, I’m not ashamed to admit that I went home and cried myself to sleep. The decision was either to focus on weight loss and suffer mentally, or accept my weight gain and avoid falling back into disordered eating habits.

In the UK, 60% of women are overweight or obese. This statistic includes 29% of women who are classified as obese. It is also incredibly important to note that, although these BMI weight categories are automatically associated with how healthy a person is, upon actual study, the system has been exposed as fairly irrelevant. In one study, almost a third of people with a ‘normal’ BMI were actually found to be metabolically unhealthy and in another, almost a third of those labelled ‘obese’ (BMI 30-34.9) were actually found to be metabolically healthy. This shows the weight bias in medicine not only being harmful in its treatment of patients, but based on the assumption that high weights are automatically unhealthy - which isn’t necessarily true.

Photo credit: Hearst Owned
Photo credit: Hearst Owned

When these correlations are created, it often leads not just to mistreatment of plus size patients, but misdiagnosis. Joan Chrisler, PhD, a professor of psychology at Connecticut College explained in a presentation titled "Weapons of Mass Distraction - Confronting Sizeism" that “research has shown that doctors repeatedly advise weight loss for fat patients while recommending CAT scans, blood work or physical therapy for other, average weight patients. Doctors could jump to conclusions or fail to run appropriate tests, which results in misdiagnosis.”

Backing this up, comes the findings, “in one study of over 300 autopsy reports, obese patients were 1.65 times more likely than others to have significant undiagnosed medical conditions (e.g., endocarditis, ischemic bowel disease or lung carcinoma), indicating misdiagnosis or inadequate access to health care.”

Photo credit: Hearst Owned
Photo credit: Hearst Owned

This dismissal of the complaints of plus size patients rings true with my own story - my inability to get the pill, as well as the years of arguing with GPs to even get tested for PCOS in the first place. I remember vividly being told as a teenager that “40% of women have some form of polycystic ovaries” instead of being offered an actual test for the condition.

Even then, at my skinniest - but still an overweight 27.11 on the BMI scale - I was told the best solution for my symptoms was simply to lose weight. At the time I was consuming only 300 calories a day and fell into a state of despair. If I’ve learnt anything from the experience, it is that weight loss should never be offered as a sole solution by the medical field.

Dr Joshua Wolrich, an NHS surgical doctor and anti-weight bias advocate, explains that the focus on weight doesn’t differ between doctors, but is an initiative within our National Health Service. “There's a ‘make every contact count’ policy where there are certain things a GP is meant to mention during every consultation,” Wolrich tells me via Zoom. “GPs are taught to discuss weight at every appointment [with every patient] and it becomes a tick box for each visit. When something like this becomes a tick box, the compassion is gone. The actual understanding and the nuance of this topic is gone.”

Photo credit: Hearst Owned
Photo credit: Hearst Owned

The issue with weight stigma, Wolrich believes, is the “personal responsibility that gets put on weight” because this “translates to a personal responsibility on disease, and conditions like type two diabetes get called ‘lifestyle diseases.’”

He continues, “Although we know that aspects of lifestyle can reduce their risk, the discussion around [weight and weight associated illnesses] puts a lot of blame and a lot of shame on the individuals who do have these conditions. We have substantial amounts of research and evidence showing just how harmful weight stigma is towards not only mental health but people's physical health as well. The point of going to the doctor should be to have somebody be compassionate towards you, and want to treat you as an individual, as somebody who they're trying to help. If the only feeling somebody gets when they go to the doctor is that they're not actually going to get listened to - that's the exact opposite of what healthcare should be.”

Photo credit: Hearst Owned
Photo credit: Hearst Owned

Roisin, a housing call centre worker, was dismissed because of her weight for years before being given her diagnosis of hypermobility and fibromyalgia. “I have been going to my doctor since I was a teenager with strains and sprains as well as suffering from chronic fatigue. I struggled with these symptoms for over ten years and I was often told to lose weight as that would help me move around easier,” she describes. “My genetic disorder was dismissed because my doctor decided that as a fat person, I'm not active, I'm depressed, I’m just lazy. The reality is my pain and injuries caused by hypermobility were dismissed repeatedly, and I truly believe I would have had a diagnosis far earlier if I was thin.”

Cindy*, a 26-year-old burlesque performer, has suffered for years - not just due to delayed diagnosis, but repeatedly being denied treatments. Treatments that, Cindy tells me, would “have potentially exposed my illness earlier and [could] have prevented the advanced deterioration of my conditions and detrimental comorbidity.”

As well as having Autism, Ehlers Danlos Syndrome, Fibromyalgia and Habitual Dislocation Disorder, Cindy also similarly suffers from PCOS just like myself. Although told she needed a smear test after an ultrasound couldn’t take a clear enough picture, Cindy’s doctor “didn’t want to do it” because “he didn’t have stirrups in the room, so it would be ‘a lot of work’ for him.”

Photo credit: Hearst Owned
Photo credit: Hearst Owned

This story is similar to a more morbid tale being told on social media recently, from bariatric and obesity nurse Toni Jenkins. She tells me via email about one patient who “was told not to return for a cervical smear until she lost weight because it was difficult for the nurse to see the cervix. She was embarrassed and didn’t return. Two years later she was admitted to A&E with abdominal pain. She had advanced cervical cancer and she died aged 32.” It is worth noting that both Wolrich and Jenkins confirmed there are no weight limits for performing a smear test.

Not every doctor will be dismissive like this, of course, but when patients are misdiagnosed, mistreated and unheard by one healthcare provider, it can feed a cycle of fear and embarrassment that it might happen again in future. This kind of discrimination can also be the reason that fat people “experience more depression” as well as causing some metabolic diseases. Wolrich says, “We know that discrimination can link directly to metabolic disease through pathways of stress and all sorts of issues.”

Fat bias is a societal problem that trips us up at every turn, and it isn’t as minor an issue as not finding clothes on the high street or needing a seat belt adaptor on a plane. In between being misheard, misdiagnosed and mistreated, discrimination against plus size people can literally kill. Although my own condition is not life threatening, there is still no treatment available to solve my symptoms because I am a fat woman. In fact, many medications simply won’t work if you are fat, with the solution being - as always - “lose weight” in order to receive treatment. Knowing what we know about the complexities surrounding BMI and medications, surely there needs to be more research conducted into the options available for women like me, rather than the blanket 'advice' we’ve come to accept.

This can all easily make a fat person feel hopeless about having to attend doctor’s appointments that may not benefit them, but there are steps you can take to try and ensure fairer treatment. Blogger Georgina Grogan compiled this list earlier this year with helpful tips, the most prudent being to impress how little you wish to discuss your weight in consultations. Based on my experiences, I agree with this recommendation; by forcing a dismissive practitioner to address their own fat bias you can fight to get the treatment you deserve. The problem is, that we shouldn’t have to be fighting for it at all.

Think you're being discriminated against because of your weight?

Four women share their tips based on personal experience:

"Be very persistent and upfront if you can. It takes a lot of courage but you know your body better than anyone else. If you're experiencing pain or an issue with your body, don't let them wave it away as weight-related. Acknowledge your weight, but also be clear about the problem, and how it is impacting your life. If you are experiencing fatphobia in a medical setting, you have every right to complain to the NHS and ask for a second opinion. Everyone deserves to be treated with dignity and empathy, especially in the scary setting of a doctor's office or hospital." - Hannah, 28, she/her, diagnosed with chronic fatigue syndrome aged 15

  • "Research what you’re going to the doctors about as much as you can beforehand - it’s much easier to advocate for yourself if you can point to research about your symptoms. If that sounds a bit overwhelming, a study about weight bias (or even this article) should do the trick - just some evidence to back up what you’re saying and make sure you’re not brushed off because of your weight." - Charlotte, 26, she/her, suffers with depression, anxiety, ADHD and chronic asthma

"The best thing I've learned along the way is to get used to saying 'I appreciate you need to weigh me for medical reasons (anaesthetic for example) but please do not disclose any numbers to me. I need to make sure you and your team are aware that I have disordered eating and am not comfortable discussing anything weight-related. Please respect this' - so far it's been pretty effective, especially with the 'well-meaning' nurses who I swear are on commission for WLS referrals!" - Lorna, 38, she/her, stage 4 endometriosis

  • "Keep pushing! If they try to compare you to someone else who is in a better situation than you health wise or weight wise to try to put you off a treatment, ignore it. If they make snide comments about your weight, even though it’s hard, ignore it and don’t let it show you’re bothered about what they think. You need a really strong head and if you are certain of something regarding your body or your health, don’t let anyone change your mind because even the GP’s can be wrong." - Tia, 22, she/her, sickle cell disease

Photo credit: Hearst Owned
Photo credit: Hearst Owned

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