Kristen Hardy explores how to change the biomedical system for the better to offer just and more complex care for fat people and members of other marginalized communities.
That fat people’s encounters with the biomedical system are often, even routinely, degrading, humiliating, and abusive is hardly a secret. The sharing of painful lived experiences of fat folks, especially fat women and fat gender-variant people, abounds in social media comments—experiences of being denied care, labelled ‘lazy’ or ‘gluttonous’, touched without consent or in demeaning or violating ways, and told, in only slightly less-direct ways, that people with their body type should not exist. Many advocates have issued pleas for reducing stigma toward fat people, as well as greater size accessibility in the physical spaces and equipment of healthcare institutions. Much of this work and advocacy emphasizes an approach that positions education—of clinicians and researchers—as the key agent for transformation of anti-fat attitudes and inequitable treatment. As an educator myself, I recognize this work to be essential. When led by those most-impacted by weight bias (particularly in intersectional ways), and undertaken with pedagogy centered in anti-oppressive paradigms, the impact on those who are genuinely receptive can be significant (Cameron and Russell 2016).
However, this approach often skirts the fact that contemporary biomedicine is constitutively fatphobic and fatmisic—rooted in, and perpetuating, both fear and hatred of fatness and fat people. Biomedical logics are grounded in a normalizing framework that inevitably frames bodies and subjects which fall outside of certain parameters as ‘abnormal’, and pathologizes these abnormalized bodyminds (Lock and Nguyen 2018). A eugenic, even genocidal, attitude toward the fat community is ‘baked in’, as it were. Because of this, education about anti-fat bias on its own inevitably falls short of producing the sort of paradigmatic change needed to end fat pathologization and fat eliminationism.
To fully understand why and how fat people are targeted, abused, and profoundly harmed within and by the biomedical system, it is vital to recognize that contemporary medicine is a product of colonialism, capitalism (Chakrabarti 2014), patriarchy (Mangham and Depledge 2011), white supremacy (Washington 2008), and ableism (Davis 2018), among other forms of oppression. These systems continue to inform the structures, practices, and ways of thinking that constitute ‘health care’ systems that, all too often, neither foster health nor demonstrate care, for clients or clinicians. It is important that our work focus upon changing systems, rather than merely calling out individual acts of bias and bigotry. There are ‘nice’ doctors and ‘kind’ nurses, just as there are bigoted and cruel ones. But oppression, as the work of scholars and activists have taught us, is not only acts of ignorance or malice—it is systemic, and often operates in covert ways, including under the guises of care and compassion (Young 2004).
Belied by the oppressive relations embedded within their own rhetoric of “patient-centred care” (people are not ‘patients’; ‘centred’ is not directed by), the relationship between biomedical providers and health-care seekers today remains fundamentally one of domination, control, and hegemony exercised through discourses, practices, and institutional and legal structures. This lack of agency and autonomy inevitably impacts people with marginalized identities severely, fat people among them.
This is a daunting problem, to be sure, but not an insurmountable one. Contemporary configurations of biomedicine are very recent in terms of humanity’s engagement with healing over the course of our species’ long history—a mere blip in an epic timeline. That many other, less-oppressive ways of thinking about and approaching the maintenance and restoration of well-being have existed, and do exist today, should hearten: another world, a better world, of health and healing is possible. Many scholars have already contributed admirably to the colossal task of unpacking the mycelium of ideologies and structures that contribute to the ‘matrix of domination’, creating medical oppression (Collins 2000). This research ranges from exposés of the racist underpinnings of BMI and medical weight bias (Gilman 2004; Strings 2019) to analyses of other manifestations of disempowerment, violence, and cultural imperialism enacted through the medical-industrial complex, especially via intrinsically abusive biomedical fields like gynecology and psychiatry (Moscucci 1990; Szasz 1997).
Rather than rehash this research here, however, I wish to offer some thoughts on concrete strategies for a radically transformed system of health care that offers the possibility of moving toward true justice for fat people and members of other marginalized communities.
Firstly, system change must be led by those most impacted and vulnerablized by these systems. Certainly, a fat-embracing health-care system must involve fat researchers and fat practitioners in prominent leadership roles, and the institution of equity polities to boost more fat people—especially fat people of color, fat disabled people, and fat queer, transgender, and intersex people—into health-care professions. However, relying solely on such an approach risks introducing a facade of diversity upon an ill-constructed edifice; even a fat MD with a weight-neutral philosophy who otherwise perpetuates the existent system can do little to pull up the tangle of intersecting forms of medical oppression by the root.
Rather, we must look to centering the voices of fat and other marginalized people in committing to and guiding the dismantling of the structures of power upon which biomedicine is based. We need to change the discourse from one of ‘improving’ existing systems of health care through ‘diverse’ input, to one of abolishing biomedicine as a form of oppression in its own right and replacing it with healing-oriented systems and practices that foster choice, respect, and equity, led by those with specialized knowledge and lived experience—of illness, of healing, and of oppression.
A correlate of this transformation is putting an end to what scholars of medicine refer to as medical dominance, or the disproportionate and unjust power held by MDs over health and health care (Freidson 1970a, 1970b). The manifestation of such dominance ranges from almost total control over the regulation of their own profession and (non)punishment of transgressions, to the shaping of laws, policies, and perspectives surrounding public health, health care institutions, and bioethical issues. This, too, is historically recent; during the nineteenth and early twentieth centuries, many countries saw MDs fight ferociously to gain social legitimacy and legal power, while attempting to stamp out the existence of rival practitioners and alternative and Indigenous systems of healing arts, concentrating power within their own profession (Brown 1997; Lock and Nguyen 2018).
Recent decades have witnessed some challenges to MDs’ power, as online access to medical research, an array of alternative diagnostic and therapeutic systems, and health-oriented social movements have granted new powers to lay people. However, biomedical physicians’ prominent public-health and media roles during the Covid-19 pandemic, combined with the appropriation of progressive discourses of medical freedom by the white-supremacist ‘anti-vax’ movement, threatens to reverse the mainstream questioning of medical dominance, by painting it as disrespectful to ‘front-line heroes’ and as linked to a (genuinely) dangerous religio-political movement. Regardless, it remains clear to many who experience abuse and degradation within existent health care systems that medical dominance must be curtailed and the structures that allow MDs to exercise paternalism (no matter how beneficent the façade) must become a chapter of medical history, not a reality of medical futurity.
The linchpins within this system of domination include MDs’ near-exclusive monopoly over requisitions for lab testing and medical imaging; their power to determine access to health- and disability-related accommodations, including in schools and workplaces; their gatekeeping of access to consultations with specialists through the referral system; and their control over access to medication and other treatment options via the prescription system. This tetrad of gatekeeping powers—over requisitions, accommodations, referrals, and prescriptions—and the relationships of literally sickening exclusion and forced dependency they create, remains the foundation of biomedicine’s medusa-like tentacles of oppression. While health care, by its very nature, involves an intense awareness of human interdependence and a need for advice and assistance, a system structured to support the hoarding of power and the denial of autonomy are the very antitheses of the mutual care and self-determination that are central to true healing, and will inevitably result in disproportionate harm to stigmatized and marginalized people.
But what can actually be done by concerned people to change this situation? Our most-powerful responses must be collective and sustained, and go far beyond fat-justice issues specifically. Use electoral power to support those candidates who are not in the back pocket of MDs’ associations and the pharmaceutical industry. Engage in advocacy and activism with health-justice organizations led by marginalized people. Pressure governments to change legislation that allows unfettered professional self-regulation. Fight for legislation and collective agreements to prevent employers from requesting ‘doctors’ notes’ for employee absences. Demand changes to laws that prohibit non-biomedical practitioners and laypeople people themselves from requisitioning tests. Join survivors’ protests against forced psychiatric detention, electroconvulsive treatment, and other abuses. Demand of politicians that medications, including contraception and abortifacients, be made available over the counter. Insist that MDs no longer be permitted to gatekeep trans people’s access to hormone treatment and other gender-affirming care. Support autistic self-advocates in fighting abusive ABA ‘therapies’, and stand with intersex people in battling nonconsensual surgeries. And, last but not least, join members of the fat community in fighting fascism through fat-positive, solidarity-based organizing, battling weight-based discrimination in Covid-19 treatment, and advocating for the abolition of pharmaceutical and surgical ‘weight-loss treatments’ in medicine. These efforts may be slow to bear fruit, but most of humanity’s social-justice gains have been products of a long arc.
As individuals, though, we must not underestimate our ability to impact the world through personal praxis. Language is a simple and accessible, yet potent, place to start. Here are some things that I do in my writing, teaching, and my everyday life—and you can do them, too. Refuse to use ‘o-words’ (ov_rw__ght and ob_se/ob_s_ty) to describe any person or any body. Be aware of how you use loaded terms like ‘normal’ in reference to bodies, health, and mental states; there are no ‘normal’ bodies or minds, only culturally valorized ones (Davis 1995). Cross out ‘patient’ on any form you encounter and correct providers when they use it in reference to you or others (take your pick of better alternatives—healthcare seeker, client, or even simply person). Do not use ‘trauma-informed’ to qualify so-called ‘diagnostic’ or ‘treatment’ practices that are inherently traumatizing, such as sexual violation and psychiatric detention; work to eliminate these, not rebrand them. Reframe oppressed people’s ‘avoidance’ of medical encounters as acts of self-care and self-preservation; fat people and others who experience systemic medical oppression intuit that they are considered ‘problems’ to be ‘eliminated’. Use descriptive language that reflects the gravity of the situation for marginalized people. (Is it ‘weight stigma’? Or is it eugenic ideology?)
If you work within a health care environment, you have even greater means to contribute to people’s control, safety, bodily integrity, and autonomy. Are health-care users, especially those with multiple marginalized identities and complex health-care needs, active members of every committee at your workplace? Are clients automatically provided with copies of all test results, health records, notes, and written communications concerning them? Are clinicians encouraged to offer phone appointments, where clients’ stigmatized identities may be less obvious and physical safety and comfort is guaranteed? Are scales, ‘examination tables’, and ‘patient gowns’ (and the demeaning and abusive practices they were designed to facilitate) banished from your facility? Does your department provide assurance of access to weight-neutral and touch-free diagnosis and care? Are in-person consultations held in office spaces, with accessible seating and transparent walls or doors left ajar (unless a client requests otherwise for confidentiality)? Are health-care seekers encouraged to take the lead in researching, choosing, and combining their treatment options from multiple healing modalities? These are just a handful of measures that can shift health-care appointments from being terrifying and traumatizing ordeals (and yes, that is the default experience for fat people), into safer, health-promoting experiences for all, even within the broader framework of biomedical oppression. Such justice-oriented interventions can literally make the difference between life and death—for clients, of course, but also for clinicians, through fostering more-humane healing relationships and reducing the burden of moral distress.
Health sovereignty and liberatory medicine are more than just appealing possibilities—they are essential to creating a society in which all bodies, all minds, and all lives are livable ones.
About the Author
Kristen Hardy (she/her) is an interdisciplinary researcher and university educator, based in Winnipeg, Canada on Treaty 1 Territory and the Métis Homeland, whose work explores relations between systems of power and the constitution of marginalized subjects with a focus on pathologization in medicine and other sociocultural spheres. A fat and disabled person, she is committed to a vision of ethical, self-directed health care.
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