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The first time I was penetrated I was thirteen, almost fourteen. The lights were on and bright. My gray sweatpants sat discarded on a chair with my stretched-out underwear. My mom was a few feet away, on the other side of a locked door. 

Moments before it happened, I was asked in a few coded but unsubtle ways if I had ever had sex. I said no. I was reminded, in case I’d forgotten, that I was a “developed girl” and “developed girls” often got “certain kinds” of attention that encouraged them to do “certain things.” But I had not forgotten; it is impossible to be a young fat Black girl and forget.

I had come to the Pediatric Emergency Department at Montefiore’s Children’s Hospital with intense cramps. I’d been sitting with my mom in a tiny room for nine hours before I was wheeled away to see a doctor. A nurse told her to stand outside and instructed me to undress from the waist down and wait. When my doctor—a thin blonde woman—entered the room, she said hello with a big smile but didn’t tell me her name. She asked whether I was sexually active but didn’t seem satisfied with my answers. Then she told me to lay back, scoot my bottom toward the end of the table, and spread my legs so she could “take a look.” She didn’t explain what that meant or what she was doing or what she had done after it was over. I screamed for her to stop, shouted “No!” over and over.  The speculum had painfully snapped inside of me a second time when she said “Wow, you really weren’t lying!” I could only sob with so much helplessness it made my throat rattle. When she finished, she said she would come back to discuss things with me, but she didn’t. I was sent home with instructions to take Motrin and “stay out of trouble.” The STI tests all came back negative. 

This is medical fatphobia. 

Medical fatphobia refers to the specific ways that hatred and denigration of fatness manifest within medicine and the fields that medicine influences, like public health. It is the reason many fat people likely didn’t get or know to ask to have their COVID-19 vaccine administered with an appropriate-length needle, and why the American Academy of Pediatrics supports bariatric surgery for fat kids despite the incredible risks. 

Mainstream writing on fatphobia usually gives in to the myth that there is something exceptional about fatphobic violence in healthcare. That fat people, in all our corpulent clumsiness, are just more likely to stumble across the assholes.

This is not true. It is a lie that has been actively propagated with the assistance of the many not-fat people who have shaped our collective understanding of how fatphobia operates. The truth is that fatphobia is a scientific invention. Fatphobia did not penetrate science; it is derived from science. Everything you know about “obesity,” about fatness, about fatphobia, about fat people has been — and is still —  wrong. 

In Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness, the Black fat queer trans abolitionist theorist notes that “for race to be constructed, the Slave had to exist—and had to exist as the antithesis of health—so that European physicians, anthropologists, and other eugenicists could determine what set the Slave apart from the… Caucasian.” 

This is the origin story of anti-fatness.

These European thinkers often focused on separating humans into different races by physical features or geographical location and ordering them from best (always White people) to worst (almost always Black people). They used perceived differences in intelligence and attractiveness, customs they witnessed on travels, and the degrading descriptions of African peoples that they read in the work of peers and predecessors. Using this race “science,” these white Europeans linked fatness to blackness by classifying fatness as inherent to non-White peoples. Swedish scientist Carl Linnaeus, who developed the binomial system we still use for naming plants and animals, defined four varieties of humans: European white, American reddish, Asian tawny, and African black. Unsurprisingly, White people were declared as the most intelligent race, while Black people were described as “lazy,” “careless,” “covered by grease,” and “ruled by caprice.” 

In the mid-1800s, new efforts to measure bodies and populations at the state level produced quantitative data that scientists and mathematicians used to invent normalcy and deviance, including ideal and non-ideal weights. Swimming among these streams of quantification was Belgian astronomer and statistician Adolphe Quetelet, who took statistical theories from astronomy and applied them to decidedly terrestrial data sets: body measurements like head circumference (aka “anthropometric” data) and population data like birth and death rates (aka “social” data). Quetelet found bell curves in both sets, with data clustering around a mean and falling sharply off on either side. At the peak of the curve, the center and highest point, is the average value for the set. For Quetelet, that peak became l’homme moyen: the average, ideal European man. In 1835, he published these findings and more in a series of books that included the Quetelet index: “If we compare two individuals who are fully developed and well-formed with each other, to ascertain the relations existing between the weight and the stature, we shall find that the weight of the developed persons, of different heights, is nearly as the square of the stature.” Ancel Keys, the weight researcher who popularized the Mediterranean Diet and created military K-rations, would go on to define an entire area of research in 1972 when he refashioned Quetelet’s Index into the Body Mass Index to measure ob*sity across different populations. The Body Mass Index was later adopted in 1985 by the National Institutes of Health in the US to define ob*sity. A decade later, the World Health Organization released a report that set the BMI categories and ranges we still use to fat people’s misfortune today. 

When you look at a fat person now, regardless of your own weight, you see a manifestation of ob*sity because of a social process called pathologization, which was first conceptualized with respect to fatness by narrative medicine researcher Rachel Fox and her team. Pathologization reduces an individual down to the qualities or stereotypes of a disease as dictated by dominant medical knowledge. When you see a fat person, you associate them with ob*sity. What you believe about ob*sity and have internalized from health authorities—its causes, symptoms, consequences, treatment, and more—then guide your interaction with that fat person. You see an affliction to be cured rather than a human being.  Fatphobia starts at the top, with scientific authorities who set the tone for how we think about health and illness, then seeps down to shape the lives of every fat person everywhere. 

When fat people are pathologized, they suffer the effects of weight stigma; this is an academic, alienating way of saying they are subject to fatphobic interpersonal, institutional, and structural discrimination. Weight stigma researchers are mostly concerned with how weight stigma relates to individual health behaviors, risks, and events like “poor” eating and exercise habits, mental illness, and mortality because most weight stigma research is in support of “obesity prevention” efforts. Rebecca Puhl and the Rudd Center for Food Policy & Health are two of the most notable sources of weight stigma research in public health.  Puhl has done Weight Watchers-funded research using WW participants enrolled across 6 different countries. This weight stigma research is specifically intended to help “obesity prevention” efforts function more effectively by giving them a less-stigmatizing veneer. They are far from the only ones. There is plenty of research to paint a gruesome picture of the social, economic, and bodily suffering that stems from fatphobia.

But.

It is proven that weight loss is a useless, hopeless endeavor. You are unlikely to lose weight in any permanent way and highly likely to open yourself to the myriad risks associated with weight cycling. The relationship between weight and health is also muddy. People often mention research that suggests that fatness (up to a point) can be protective, but this often only has the effect of scapegoating the fattest among us, the infinifat people who are only acceptable to acknowledge via mocking entertainment. If you decide (or are pressured to) pursue gastric bypass surgery in order to escape fatphobia violence, you may not actually lose weight  — for some, the main outcome is disordered eating, an attempt to salvage the benefits of an incredibly harmful and risky procedure. No study measuring the association between weight and health outcomes comes close to appropriately accounting for the impact of fatphobia on an individual’s wellbeing, including how those impacts are likely the worst for the fattest among us. 

There is no fitness regimen that can keep you moving when doctors refuse to perform a joint surgery you need. There is no diet that can keep you alive when your doctor dismisses the constant pain or discomfort you’re begging them to acknowledge. There are no “health-conscious” behaviors that can nullify the harm done by health authorities who’ve made fat embodiment into disease and weight loss into cure. The only escapes that fat people are offered from a micromanaging, soul-draining existence are weight loss or death. And when we wisen up to the improbability of long-term weight loss, there’s only one option left. 

There are many things people don’t quite understand about medical fatphobia. It is more than whether we can pass on getting weighed at the doctor’s office. It is more than healthcare avoidance, although being disrespected, perceived as noncompliant, and exposed to harm by medical professionals are significant obstacles to accessing care. It is more than the potentially lifesaving cancer and breast screenings exams we do not receive and the eating disorder treatment we are deprived of. 

Here are the three things people get wrong most often, in no particular order.

One: There is no difference between a) providers who are horrible to fat people because they openly hate us, b) providers who are horrible to fat people because they think it’s the best way to get us to lose weight, and c) providers who are horrible to fat people because they haven’t bothered to learn how not to be. There is no difference to the patient, or the outcome. A healthcare provider’s motivation for harming fat people, often via denying us vital care unless we lose weight, does not justify the harm done or make it any less unethical.

Three. Medical fatphobia isn’t the result of providers not knowing some special cheat codes for working with fat patients. Providers didn’t all miss the day in medical school when students were taught how not to be cruel to fat people. Medical fatphobia is medicine’s status quo. 

Robert Rosencrans is an MD/Ph.D. student at the University of Alabama at Birmingham’s School of Medicine. “With fatphobia specifically,” he says, “the idea of fatness being intrinsically linked to sickness is so fundamental for most people in medicine that they simply have no idea what you are talking about when you raise a critical point [questioning ob*sity]. It’s like the words lose all semantic content and revert to pure meaningless sound. That’s how profound the disconnect is.” As he wrote in ASBMB Today:

All-cause mortality is as high in underweight people (as defined by body mass index) as it is in patients with higher BMIs … For a thin person, the average scientist and physician believes that cancer, not thinness, is killing that patient. They can locate the source of mortality in something other than body weight or adipose stores. What scientific reason prevents them from extending the same courtesy to larger people?

This is, in part, why most of the weight loss advice you’ve ever received from your doctor is grounded in regurgitated mythologies with no evidence base. Consider the common refrain that “losing just five to ten percent of your body weight has substantial health benefits,” which gets trotted out with thinly veiled exasperation by a doctor that wants you to just try to be less fat or by a weight loss advertisement that is begging to throw you into a yo-yo dieting tailspin. It’s been repeated so many times that it has become accepted as health wisdom, like many things we’re told about weight loss. But a 2013 review of weight-loss diets and their health outcomes exposes the history of this advice:

The original standard weight recommended by physicians was based on the Metropolitan Life Insurance Tables…[T]he tables designated 134 lb as the expected weight for an average-height woman (5′5′′) of medium body frame. Whatever her starting weight, 134lb would be her goal. Obese dieters, however, rarely achieved these standards. Researchers turned to what they considered to be the more realistic goal of 20% weight loss, but only 5% of obese dieters succeeded by that definition. Over the next 30 years, reviews of diet studies showed that individuals tended to lose an average of about 8% of their starting weight on most diets). In an effort to create a more achievable goal, but without any particular medical reason, researchers lowered the standard to just 5% of one’s starting weight.

That’s it. Some people, somewhere, at some point made it easier for diets to be classified as “successful” and that is the reason why we, decades later, have to listen to this little tidbit of nonsense while getting horrible medical care or being accosted by ads for whichever fad diet is interrupting our favorite podcast. 

Our lack of knowledge about lipedema—including its etiology, appropriate non-invasive treatments, and methods of early detection—is a consequence of fatphobia. A culture that heavily polices fatness depends on us not knowing very much about fat at all.

The medical fatphobia that endangers fat patients also endangers our communities via our public health system. Public health in the U.S. has been largely guided by medical doctors since its inception. Public health students are taught that our work is a population-level complement to healthcare’s individual approach to health promotion. Similarly, public health’s fatphobia works in tandem with medical fatphobia to erode the well-being of fat communities while claiming to advance health equity. 

According to the CDC, health equity “is achieved when every person has the opportunity to ‘attain his or her full health potential’ and no one is ‘disadvantaged from achieving this potential because of social position or other socially determined circumstances.’” It stands to reason that fatphobia should be of concern to health equity researchers and advocates; after all, fat people are structurally, socially, and materially deprived of the opportunity to live out our “full health potential” on the basis of fatphobia alone, and many, if not most of us, are multiply marginalized. Unfortunately, the realities of public health mean that most health equity work is not actually conducted with equity in mind. As Dr. Elle Lett and her co-authors argued in a recent commentary on health equity tourism, plenty of (usually White) people without experience in or commitment to promoting health equity have flocked to the health equity space because they see the potential for research productivity or fiscal return. Many also try to shoehorn their existing work into the health equity framework: “Oftentimes, these scholars seek to ‘retrofit,’ or adapt existing structures and research practices for health equity work, rather than build the necessary transformative infrastructure required for sustainable health justice.”  

The Treat and Reduce Obesity Act, which was first introduced in 2013 and has always had bipartisan support, claims to promote health equity using the backward approach Kriete describes. One proposed element of the Act would broaden Medicare coverage for intensive behavioral therapy to reimburse more providers, as well as cover FDA-approved weight loss medications under Medicare Part D. A supportive op-ed by Dr. Fatima Cody Stanford and Kelly Copes-Anderson points out that “nearly 50% of Black adults and 45% of Hispanic adults have obesity,” before arguing that “the significance of these two advancements goes beyond treating individuals with obesity. They represent a decisive moment in shifting society away from viewing obesity as caused by individuals making poor choices and toward treating obesity as a manageable chronic disease like asthma or high blood pressure. This is a crucial step in eliminating bias against people with obesity, which has hobbled efforts to address this epidemic even as it fuels health inequity.”

According to the Centers for Medicare & Medicaid Services’ Open Payments website, which has data on payments made by drug and medical device companies to physicians and teaching hospitals between 2016 and 2020, Stanford received over $17,000 from pharmaceutical giants like Novo Nordisk. By her own admission, she does up to 200 interviews with news media and an average of 150 lectures per year about “obesity as a disease.” Her co-author, Copes-Anderson, is employed by Eli Lilly as their head of diversity, equity, and inclusion. Eli Lilly is currently awaiting FDA approval of its anticipated ob*sity medication tirzepatide and hopes to follow in the footsteps of competitor Novo Nordisk, which is making billions from sales of its ob*sity drug, Wegovy, released in 2021. If the Treat and Reduce Obesity Act is successful and Medicare Part D coverage includes drugs like tirzepatide and Wegovy, pharmaceutical companies will make a killing, as will “obesity medicine” practitioners .

This is the fatphobia industrial complex: the cluster of entities using fatphobia to sell products and services that provide the influence and capital needed to exert control over large swaths of people and regulatory bodies for the purposes of making profit, repeated ad nauseum. Their appropriation of health equity language is a tool to further the idea that ob*sity is a disease requiring prescribed cures, making pharmaceutical companies and ob*sity specialists into fat people’s saviors. And their ability to do these things while referencing research that demonstrates the uncontrollability of weight—research that well-meaning people use to criticize fatphobia—is further proof that fighting for fat people’s rights on the basis of how healthy they are will never make us free.