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A Different Kind of Understanding

by Fall Ferguson, JD, MA

Next week is Weight Stigma Awareness Week. As I pondered what to write about that, I found myself getting irritated that we need an awareness week. (Perhaps a recent viewing of Morgan Freeman schooling Mike Wallace on Black History Month was influencing me.)

The problem of weight stigma is well-described in the literature. Why are so many health and wellness professionals and policy makers oblivious to the harm caused by weight stigma? Stigma and bias are generally understood to be social determinants of health. What would it take for size to be included as a source of health inequities, just as race, ethnicity, gender, sexual identity, age, socioeconomic status, and geographic location currently are?

Starting with an assumption that most health and wellness professionals and policy makers think they are doing the right thing by emphasizing weight, how do we persuade these do-gooders that they are not, in fact, doing good? The short answer is, the research is necessary, but it’s not enough. We need to foster a different kind of understanding.

Sailors, Prostitutes, and Circus Sideshow People

seeing patients cover

In Seeing Patients: Unconscious Bias in Healthcare, African-American physician and Harvard medical professor Augustus A. White III, MD recounts his journey to understanding the impact of bias and stigma. White broke through many barriers to succeed in his profession and was familiar with the literature on health disparities, yet the role that stigma and bias play in health outcomes was not immediately apparent to him until “one event in particular triggered a different kind of understanding for me” (p. 195).

The event? During an airplane journey in the late 1990s, he sat next to an attractive, “normal” young woman who revealed that she was a tattoo model whose body was (other than her face and hands) 100% covered with tattoos. He recalled a medical school lecture in which slides of tattooed bodies were presented as belonging to “sailors, prostitutes, and circus sideshow people,” as well as convicted criminals. Dr. White noted that the lecturer had clearly conveyed that heavily tattooed people were “[n]ot really up to the level of normal people—like those of us in the lecture hall” (p. 196). His inability to reconcile his perceptions of his seat companion with the perspective he had learned in medical school has a name: cognitive dissonance.

Because They Treat Me So Badly

The young woman then revealed she hated to go to doctors “[b]ecause they treat me so badly.” Dr. White immediately understood: “I pictured her sitting in a doctor’s office unclothed for an examination. I could just see the stares, the amazement, the intrusive questions, the doctor maybe inviting one or two others in to take a look. … And how would this doctor treat her? … He would almost assuredly approach her with something other than simple objectivity and compassion for whatever it was that was troubling her” (p. 196).

Dr. White’s cognitive dissonance cracked open his understanding and allowed him to link data about health disparities with a deeper awareness of how stigma affects the doctor-patient encounter:

I had actually seen that kind of thing more than once. Not with tattooed people, but with obese people and elderly people. I knew doctors who did not relate to these patients as they should have, who were a little put off or impatient, who weren’t as attentive as they would have been with someone more supposedly “normal.” …

That night I was thinking over my talk with the tattooed young woman and suddenly something clicked … this girl was “other.” [In comparison with patients who are “other” racially, ethnically, or culturally “other” she] was the same as they were, “other” in a way that would inevitably trigger reactions from doctors that were neither sympathetic nor especially compassionate. And those visceral reactions were very likely to affect the medical care they provided. They might be a little less engaged, a little more rushed. They might be more likely to allow stereotypes to enter into their judgments. You didn’t have to be an overt racist or bigot of some sort for this to happen. … It would be enough to have feelings of distaste or discomfort, even feelings you might not acknowledge to yourself, or maybe weren’t even explicitly aware of. “(p. 197)

This event brought about what Dr. White describes as a “revelation” about the detrimental effects of even subtle biases. He went on to spearhead the infusion of cultural competency training into the curriculum at Harvard Medical School, no doubt influencing medical school curricula everywhere.

Transformative Learning Requires Cognitive Dissonance

Transformative learning theory concerns how adults can change their frames of references, such as beliefs, assumptions, preconceptions, and perspectives. From the educator’s perspective, it’s about creating the conditions for the learner to undergo an authentic and lasting transformation of some kind. Significantly, the first three steps of the transformative learning process involve disorientation, emotional reaction to the new information, and examination of assumptions. In essence, it’s the deliberate introduction of cognitive dissonance for the purpose of facilitating transformation. You can see this process reflected in Dr. White’s account of his “revelation” experience.

In a recent TED Talk, Peter Attia, MD recounted how his own experience of cognitive dissonance led him to rethink his perspectives on “obesity.” He described judging a patient in the ER where he worked because she was a fat woman with diabetes; he saw her as at fault for her poor health. He subsequently gained weight “despite doing everything right,” and was diagnosed with metabolic syndrome (which includes insulin resistance and is regarded as a precursor to diabetes). The disconnect between what the medical profession (of which he was a part) said about fatness and blood sugar and his own lived reality caused him to reexamine his entire paradigm around the etiology and treatment of diabetes. Dr. Attia ended his talk with an apology to the woman in the ER:

I’d like to tell her how sorry I am. I’d say as a doctor I did the best with the clinical care I could, but as a human being, I let you down. You didn’t need my judgment and my contempt. You needed my empathy and compassion. And above all else you needed a doctor who was willing to consider, maybe you didn’t let the system down. Maybe the system, of which I was a part, was letting you down. If you’re watching this now, I hope you can forgive me.”

To “achieve health equity, eliminate disparities, and improve the health of all groups” is one of the four “overarching goals” of U.S. national public health strategy. That health inequities need to be eliminated is not up for debate. The challenge is to add weight stigma and size bias to the list of social determinants of health that people consider when developing programs and campaigns to address health inequities, whether the setting is medical and allied health treatment, public health initiatives, school policies, or community wellness campaigns. Some constructive cognitive dissonance in the form of the human face of weight stigma is called for. We need to crack open their understanding and make room for the humanity.

Recall Dr. White’s “different kind of understanding” brought about by coming into contact with a new perspective that brought the human face of the “other” to his awareness. We need to make the voices of all people treated badly or judged because of their size or weight—large, small, thin, fat—audible to folks who ordinarily can’t hear them. The stories, the anguish, and the shame need to be heard.

I am very proud that ASDAH is already working on the Resolved video project (with assistance from the Size Diversity Task Force). The video is designed to educate health care practitioners and will center on the voices of patients who have been subjected to size bias. We unveiled the trailer at our recent conference, and everyone who has seen it has been powerfully affected. Now filming is almost complete, and we are launching a campaign to raise the funds to complete the editing and other post-production activities. I hope readers will watch the trailer and consider donating to our GoFundMe campaign.

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