The Problem With Body Positivity: As Long as Doctors Judge Your Looks, Nothing Will Change

I was in my twenties the first time a doctor refused to touch my fat body.

I'd had challenging experiences with health care providers before. Nurses insisted on taking my blood pressure repeatedly, disbelieving that it could be low. After an urgent care visit for an ear infection, another doctor prescribed antibiotics—and weight loss. ("Did he think your ear canal got fat?" a friend quipped afterward.) But none bore the stinging shame of this one:

I was 25, both fat and queer, neither of which I felt confident my medical care providers were prepared for. As a fat person, I had become accustomed to care providers' pained winces at the sight of my body, and the long and condescending lectures that so often followed. And upon learning that I was queer, most doctors would assume I didn't need STI screenings and that reproductive health care wasn't an issue for me. (It was.)

I steeled myself as I entered this doctor's office, noticing a stiffness in my joints and muscles as I changed into a too-small hospital gown and awaited the doctor. He was older than me, but still young in his early forties, his eyes punctuated by crow's feet and his mouth, laugh lines. He walked in smiling and, upon seeing me, his expression changed.

When confronted with the prospect of examining my 400-pound body for a routine checkup, he physically recoiled, his face a mask of disgust. He cast his eyes away from mine, looking anywhere else, as he launched into a lecture about weight loss that I had heard countless times before: Being overweight is unhealthy, but being morbidly obese is inexcusable. You've got to lay off the fast food. You've got to get moving. Don't you want to be around for your future children?

I cooked my meals at home, walked five miles a day to get to work and back again, and didn't plan on having children. I had an eating disorder, too, borne of decades of weight-loss attempts, but none of that mattered to him. Before I had a chance to respond, he shuffled out of the room, no questions asked. A medical tech returned to let me know that my visit was complete. "You can see yourself out the way you came," she said, eyes sharp, voice cold, words clipped.

I was awash in confusion, then consumed with shame.

I longed for the kind of health care my thinner friends described: respectful, curious, and kind providers who believed their patients, touched their bodies, ordered tests, prescribed treatments. I longed for a conversation between two humans, something warm and reciprocal. Instead, I listened silently to a canned lecture.

I wondered how thin I would need to become in order to earn the kind of health care my thin friends got—a privilege that increasingly seemed reserved for those already perceived as healthy. A decade of dieting and "lifestyle changes" had not made me thin, but it had left me with a nascent eating disorder. I felt trapped, not by my body, but by the cultural insistence that my body would need to transform radically in order to prove worthy of health care.

A few short years later, I heard about body positivity for the first time from a coworker. When I got home, I scoured the internet for pages about body positivity, reading all I could find. It felt ripe with promise: a movement, or at least a framework, that could make room for those of us whose bodies were placed squarely on the sidelines. Fat people, yes, but also trans people, disabled people, intersex people, and more. This, I felt certain, was the movement that could insist upon the validity of my body as it was, not as it was expected to be.

It took years to learn how wrong I was.

The history of the body positivity movement is contested and murky, but this much is clear: body positivity wouldn't exist without the activism of The Fat Underground, a radical collective of fat lesbians who, in 1978, penned the Fat Liberation Manifesto, a list of demands published in off our backs, a long-running feminist magazine. The Fat Underground clearly situated their struggle for acceptance as one that had to exist in solidarity with poor people, people of color, colonized people, and disabled people. They were radicals with demands for significant shifts in culture and institutions alike.

But when body positivity became mainstreamed in recent years, highlighted by advertising campaigns and fashion magazines, it became clear that only some bodies qualified. Campaigns like Dove's 2004 "real beauty" claimed to champion "all bodies," but only showed those free of fat rolls, disabilities, or disfigurements. In 2012, Australian bodybuilder Taryn Brumfitt was lauded for posting a photograph of her postpartum body: less muscular, but still thin, able, lithe, white, and only slightly softened near her belly and thighs. By 2015, Amy Schumer was praised for her bravery by posing naked as a size 6 for legendary photographer Annie Leibovitz's "WOMEN." One could only be body positive, it turned out, if their skin was already pore-less, if fat rolls only showed when slouched over, if no visible disabilities could be found. Body positivity wasn't an explosion of the beauty standard but a moderate revision of it.

People who consider themselves body positive often offer caveats. "I'm body positive unless you're obese" counts me out. "I'm body positive as long as you're healthy" leaves out chronically ill people. Disabled people often feel left out of the conversation as well. Yes, you should love your body, but only if your body is already culturally defined as lovable. Despite its radical language, body positivity isn't getting to the root of much at all.

Despite its radical roots, body positivity as it exists today doesn't address social biases and discrimination, major drivers of health inequality. Those of us in marginalized bodies—fat people, trans people, disabled people, and more—often face significant stigma and discrimination. When that prejudice adds up, it can cause mental and physical health issues that researchers describe as minority stress. Research suggests that this chronic stress can lead to heart disease, diabetes, depression, autoimmune disorders, and more.

The health disparities we experience are stark. Black folks' life expectancy is four years shorter than that of white people. Latinx people—whose very existence in the US has been used as a political football, largely through racialized attacks on immigrant communities—may experience elevated health risks, including preterm births and increased likelihood of cardiovascular disease, though more research is needed. According to a study published in Obesity: A Research Journal in 2005, 98% of fat people have experienced weight stigma from their families and partners. And according to a 2018 study in the journal BMC Medicine, there is now data to support that weight stigma may be the largest driver of the so-called "obesity epidemic." That same study found that experiences of weight stigma can lead to weight gain, triggering "obesogenic processes," increased cortisol levels, decreased mental health, and possibly higher mortality overall. That is, the more fat people experience weight stigma, the more our health suffers.

No matter how much we love our bodies, those of us living on the margins can't love our way to good health. That requires more than a simple mind-set shift. In that way, body positivity is The Secret of health care: a belief that simply changing our minds can manifest some brave new world. But public health professionals have long stressed that our health isn't just a matter of our individual behaviors—it's also significantly shaped by social determinants of health like discrimination and access to education, employment, housing, and health care.

Even when people in marginalized bodies try to access health care, we may still experience significant medical bias. While health care providers receive a great deal of technical training, few are asked to uproot their own internalized biases—and for the patients they're biased against, that can lead to substandard care. Science backs this up.

Doctors develop less rapport with fat patients and spend less time with us, according to researchers at Rice University. In a 2012 study published in Obesity by widely respected researchers Rebecca M. Puhl and Kelly Brownell, 69% percent of fat women reported experiencing weight stigma from their doctors. In a 2003 University of Pennsylvania study, more than 50% of physicians described fat patients as "awkward, unattractive, ugly, and noncompliant." According to the American Journal of Public Health, weight stigma harms both physical and mental health and can even create health disparities: "Despite decades of science documenting weight stigma, its public health implications are widely ignored."

Transgender patients, too, experience overwhelming bias in medical and wellness settings. In a survey of more than 6,450 transgender and gender non-conforming people conducted by National Gay and Lesbian Task Force and the National Center for Transgender Equality, nearly

1 in 5 transgender patients reported being turned down for health care outright because of their gender identity or expression. Twenty-eight percent claimed to have been harassed by their health care providers, leading them to postpone medical care to avoid discrimination.

Research also overwhelmingly illustrates medical bias against patients of color, especially black patients. A 2016 survey of 418 University of Virginia medical students and residents shed light on this deeply troubling trend. Twenty-one percent of first-year medical students surveyed believed that black people have stronger immune systems than white people, and 19% of second-year students surveyed believed that black patients' nerve endings are less sensitive than those of their white counterparts. In response, the American Bar Association wrote, "Black people simply are not receiving the same quality of care that their white counterparts receive." No amount of self-love will fix these entrenched, institutionalized disparities.

Loving your body is a fine goal, particularly for folks whose biggest body-related problems are clustered around self-esteem and a lack of self-love. Who wouldn't want to lay down arms in the battles so many of us wage against our own skin? Our bodies draw out the deep-seated biases of those around us as we enter a room.

In the doctor's office that day, when his hands shrunk away from my wide and soft skin, he didn't care how much I loved myself, or how confident I was. His bias overtook the both of us, so much so that he couldn't even meet my eyes, touch my skin, hear me speak. And no amount of loving my curves would change that.

Body positivity isn't in itself destructive, but it's far from the radical force so many of us seem to think it is. Indeed, body positivity seems to be fortifying the beauty standard with the added burden of an equally fickle health standard—one that continues to center on more privileged bodies. Nearly all of us will get sick, grow old, get fat, grapple with mental illness, or otherwise lose our tenuous grasp on such narrowly defined health at some point in our lives. And whether or not we love our bodies in times of ill health, we still deserve care, dignity, and trust.

Yes, you have permission to love your body, and I hope you do. But so many of us need a whole lot more than that. We need providers who prioritize their patients' care over their own biases. We need health care systems that hold space for all patients, regardless of what they look like, what they earn, or how they identify.

I don't need to love my body. I need providers that can care for it.

Your Fat Friend is an anonymous essayist who writes about the social realities of life as a very fat person. Her work has been translated into 19 languages and covered around the world, and has appeared in Vox, Gay Mag, SELF, Paper Magazine and more.