As Coronavirus Rages, We Need to Talk About Medical Anti-Fat Bias

As COVID-19 cases surge once again, like many others, I find myself worrying about what will happen to me or the people I love should we contract the coronavirus. And as a fat person, I wonder, too, about the quality of care that will be made available to fat people by providers who are valiantly working their hardest, but may not have confronted the biases many have been taught surrounding the treatment of fat patients. And like countless fat patients before me, this question isn’t an academic one. It has shown up time and time again in my own search for health care. Whether I am seeking a routine checkup or treatment of acute symptoms, one thing has been made clear to me time and time again: The size of my body will heavily influence the quality of health care I receive.

Years ago, I was visiting family in California when my hearing cut out. It was disorienting and alarming, losing one of my senses so abruptly. The world sounded muffled, like it was tucked away behind a closed door, distant and unreachable. A sharp pain somewhere between my ear and my skull served as a piercing reminder of the loss of my hearing. Alarmed and sympathetic, my mother drove me to the nearest urgent care that takes my insurance.

The nurse who greeted me was kind and warm. We talked freely as she took my vital signs, though our conversation was complicated by my failing hearing. She took my blood pressure, then looked at the cuff with a crooked frown. She took my blood pressure again, then made the same face. She excused herself to get another cuff—larger, this time.

I felt my heart beating in my throat. What if something’s wrong?

“What’s the matter?” I asked, trying to temper the frightened shake of my voice.

“I’m just not getting a good read,” she said, adjusting the cuff once again.

“Is everything okay?” I asked, more afraid than before.

“It’s coming back great,” she said, the good news belied by her befuddled tone. “But that can’t be right. Obese patients don’t have good blood pressure.”

She had learned that being fat meant being sick, and invariably, that sickness would lead to death. Just looking at me, she became certain that I must be in poor health. And her certainty was so great that it overrode the data in front of her. My sickness was inevitable, so good health was unfathomable.

I entrusted her with my health, and she couldn’t see it.

Among fat patients, my experience is not unique—and it’s far from the worst of its kind. In 2018, Rebecca Hiles made headlines with her story of what she describes as medical neglect. As a teenager, Hiles had developed walking pneumonia that stayed with her for years. When she began to cough up blood, doctors prescribed an inhaler, and in subsequent visits, doctors insisted she should “just lose weight,” Hiles said. Later, Hiles’s coughing led to bladder leaks and vomiting. It took six years to find a doctor who would refer her to a pulmonologist. Shortly thereafter, a CT scan revealed a malignant tumor, leading to near-immediate surgery. Hiles lost her left lung, “the bottom half of which was a black, rotting piece of dead tissue.” She soon learned that an earlier diagnosis at one of her countless doctor’s appointments and emergency room visits could have saved her lung, and that a later diagnosis could have cost her her life. It seems as though for years, Rebecca Hiles’s doctors could only see the risk they projected onto her by virtue of her body, ascribing her symptoms to her size rather than her cancer. Only years later did she find a provider who saw her as someone whose health needs might be as complex or dire as a thin person’s.

Like the rest of us, doctors, nurses, and health care providers of all stripes have internalized deeply flawed, harmful stereotypes and judgments about fat people. But unlike the rest of us, health care providers are in positions of immense power. We count on them to define what the symptoms in our bodies mean. We count on them to tell us how to prolong our lives and stave off early death. And we count on them to interpret our bodies clearly for us, trusting them implicitly with our very lives. But for fat people, as stories like Rebecca Hiles’s show, health care providers’ interpretation is clouded by their judgment with staggering regularity. And despite health care providers’ extensive training on the mechanics of our bodies, the training is modeled on the realities of thin bodies and rarely teaches providers to confront their own bias. In some cases, it may even enhance their bias.

Over the last two decades, a growing body of research has indicated a frightening trend of anti-fatness among health care providers. In 2001 the International Journal of Obesity published a study that found those anti-fat judgments caused material differences in the outcomes of care received by fatter patients. In office visits with fat patients, the study found that many of the 122 physicians surveyed wrote notes “suggesting a belief that those who are overweight must also be unhappy and unstable.” Fat patients also received office visits that were 30% shorter. The fatter the patient, the more likely the doctor was to describe the office visit as “a waste of their time” and the patients as “more annoying.” If a physician saw more fat patients, they said, they “would like their jobs less.”

A 2003 study published in Obesity Research confirmed that “primary care physicians view obesity as largely a behavioral problem and share our broader society’s negative stereotypes about the personal attributes of obese persons.” Of the 620 physicians who participated in the study, more than half described fat patients as “awkward, unattractive, ugly, and noncompliant.” Over one-third called fat patients “weak-willed, sloppy or lazy.” Among health professionals specializing in the study and treatment of obesity, research findings are similarly bleak. In a 2012 Obesity study, researchers used Harvard University’s Implicit Attitudes Test to measure weight bias in 389 researchers, students, and clinicians. Participants overwhelmingly believed that fat people were “lazy, stupid, and worthless.” As the study’s authors note, “The stigma of obesity is so strong that even those most knowledgeable about the condition infer that obese people have blameworthy behavioral characteristics that contribute to their problem (i.e., being lazy). Furthermore, these biases extend to core characteristics of intelligence and personal worth.” Even the experts to which fat people are expected to entrust our health and our very lives exhibit not only implicit bias but explicit personal judgment of the patients they study and treat.

And those attitudes aren’t just internal—they significantly impact the care fat patients receive. Another study, published in the journal Obesity, found that primary care physicians “demonstrated less emotional rapport with overweight and obese patients.” In 2009, the Journal of Clinical Nursing published a study finding that anti-fat attitudes extended to nurses, too, and that professional nurses were more likely to harbor anti-fat bias than nursing students. “The majority of participants perceived that obese people liked food, overate, and were shapeless, slow, and unattractive. Additionally, over one-half of participants believed that obese adults should be put on a diet while in hospital.” Yet another study of more than 300 autopsies showed that “obese patients were 1.65 times more likely than others to have significant undiagnosed medical conditions […] indicating misdiagnosis or inadequate access to health care.” Even providers who specialize in eating disorders can exhibit significant anti-fat attitudes.

Medical students exhibit striking rates of anti-fat bias, too, according to a 2013 study in the journal Obesity. Seventy-four percent of the 4,732 medical students surveyed for the study exhibited some form of anti-fat attitudes, including dislike, blame, and fear. Sixteen percent slightly, moderately, or strongly agreed with the statement “I really don’t like fat people much,” 13.5% reported that at some level they “have a hard time taking fat people seriously,” and 36.6%—over one-third of medical students—held the belief that “fat people tend to be fat pretty much through their own fault.” Research shows that anti-fat bias may be contagious, catching from doctors to the medical students they instruct. In one of their studies, Mayo Clinic researcher Sean Phelan, Ph.D., asked 1,795 students if they had witnessed medical school faculty making jokes, making derogatory statements, or taking discriminatory action against fat patients. On average, students’ explicit bias increased during the course of medical school, often influenced by faculty’s openly anti-fat attitudes and actions. “We found that having experienced these things was a predictor of weight bias getting worse over the course of medical school. It speaks to a hidden curriculum,” said Phelan.

The evidence we have about the impacts of weight stigma is troubling at best. One study showed that when participants experienced anti-fatness, “their eating increases, their self-regulation decreases, and their cortisol (an obesogenic hormone) levels are higher relative to controls, particularly among those who are or perceive themselves to be overweight.” Another found that experiencing anti-fatness led to avoidance of exercise. Most damning of all, a study engaging 13,692 older adults found that “people who reported experiencing weight discrimination had a 60% increased risk of dying, independent of BMI.” Anti-fat bias, not fatness itself, may be fat people’s greatest health risk.

But when it comes to turning the tide of medical bias against fat patients, research shows there’s hope in a number of tactics, some of which are surprisingly simple. In a small 2011 study, researchers found that just one lecture on weight stigma and weight controllability significantly reduced psychology students’ anti-fat bias. (Notably, following the lecture, students were also less likely to describe fat people as unattractive.) A similar study in 2013 found effective bias intervention with a video that was just 17 minutes long. A 2012 study found that health care professionals who watched short films designed to reduce anti-fat bias did indeed curb their explicit bias, though their implicit attitudes remained intact.

Thankfully, research shows that even small efforts can begin to make a change. A meta-analysis of weight bias interventions found that, while none fully eradicated anti-fat bias, many led to a “small to moderate” shift in attitudes. But given the relentless stigma so many fat patients face at the hands of their health care providers, even a small change could make a major impact. All we have to do is try. And in the midst of a pandemic—one that’s frequently being used to further scapegoat and stigmatize fat people—trying may be a matter of life and death.

Adapted from What We Don't Talk About When We Talk About Fat by Aubrey Gordon (Beacon Press, 2020). Reprinted with permission from Beacon Press.

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