Industry Voices: Weight Is a Social Justice Issue
Amy* has been experiencing muscle pain and headaches for the past few months. Over the course of multiple sessions, the two of us have talked through her hesitancy to make and attend a doctor’s appointment to address these concerns. Despite the impact these symptoms are having on her daily functioning, she struggles to follow through.
Given my profession as a social worker, readers may assume that I am seeing Amy to address anxiety. However, Amy’s primary presenting concerns are her history with disordered eating and body image struggles. She is worried that her doctor will encourage weight loss to reduce her symptoms without offering any other viable treatment options. This fear is valid—it has happened to her many times before. She’s been chastised for weight gain and applauded for weight loss by her health care providers—even when the weight loss was obtained through disordered eating behaviors.
Experiences such as these have been eating disorder triggers for Amy in the past and, understandably, she does not want to face another triggering situation.
It’s not only their absence from this social justice conversation that is worrisome, but also their complicity in perpetuating fatphobia and related discrimination in social work practice. As social workers, we have a responsibility to combat our internal fatphobia, the collective anti-fat bias within our profession, as well as that of society at large.
Anti-fat bias is common in the field of social work (Lawrence, 2019; Shinan-Altman, 2017) and mental health treatment in general. Large-bodied individuals receiving mental health care treatment report experiencing microaggressions and discrimination at the hands of their mental health care providers. These experiences further exacerbate the very distress that often contributes to their presenting psychological symptomology in the first place (McHugh & Chrisler, 2019).
Examples of fatphobia appearing in clinical mental health practices are plentiful: Large-bodied individuals are less likely to be diagnosed with and treated for eating disorders (Sonneville & Lipson, 2018), they are more likely to be diagnosed with more severe iterations of major depressive disorder than their thin peers (Forristal, 2018), and anti-fat attitudes significantly predict a counselor’s assessment of the importance of addressing weight in the therapy room (Feister, 2012). Additionally, large-bodied individuals in therapy have reported unwelcoming microaggressions that are detrimental to the therapeutic alliance. These include feeling as though their providers were less interested in their distress and having providers assume that weight is a topic the client wants to address in therapy (Warren, 2019).
The intersection of race and class with fatphobia also plays into fat-biased social work practices. Concerns regarding the weight of a child can inform paternalistic assumptions related to the child’s welfare (Friedman, 2015), and nonwhite clients are expected to be “immune” to eating disorders because of assumed differences in cultural expectations regarding body size (Bordo, 2013; Sonneville & Lipson, 2018).
Social Work Needs to Step Up
An article by Barry Panzer (2020) in NASW’s Social Work Advocates magazine demonstrated the lack of evolution on this topic when it asked why there are not more social workers involved in the conversation surrounding the childhood “obesity” epidemic. The article did not approach this concern from a social justice perspective, but rather presented the “obesity” epidemic as, among other hyperbolic and stigmatizing parallels, a national security issue, and argued that because psychological disorders are often comorbid with “obesity,” social workers are essential in the treatment thereof.
The manner in which Panzer framed his argument reinforced fatphobic thinking inasmuch as it othered and shamed large-bodied children under the guise of promoting health. This approach falls prey to the common fallacy that weight-stigmatizing approaches promote weight loss (Hunger et al., 2020), resulting in the perpetuation of a rhetoric that is more damaging to health rather than the health-supportive perspective it purports to be.
It appears that the social work field’s current position suggests that the way to support people experiencing weight stigma is to help them not have the kind of body that makes them exposed to such stigma in the first place. This convoluted reasoning runs counter to social justice values. The position is particularly damaging when, despite popular opinion to the contrary, individuals have little control over their natural body size (Logel et al., 2015). It is further damaging given that we have no proven, long-term way of helping someone change their body size but do have evidence that attempting to do so is more detrimental to physical and emotional health and not health-supportive (Bacon & Aphramor, 2014; Harrison, 2019).
Steps to Improve
Without a universal reckoning of fatphobia, weight-based discrimination, and the harm they cause, mental health care professionals will continue to exacerbate the very distress their clients seek to address by unwittingly participating in a fatphobic medical model (McHugh & Chrisler, 2019). Social workers can become leaders in the anti-fatphobia movement by adopting and promoting as best practices a working framework designed to support clients of all sizes.
Health at Every Size® (HAES®), a health-supportive paradigm for patient care that prioritizes size inclusivity and celebrates body diversity, is one such framework. As of August 2020, the prevalence of HAES®-affirming social workers is woefully small: Of the 17,024 individuals who have signed the pledge to provide HAES®-affirming care, there are only 154 registered social workers (HAES® Community).
Social workers can also become more prominent in the curation, critique, and validation of research articles guiding HAES®-informed treatment guidelines. Panzer’s article notes the problematic lack of social workers on the editorial boards of “obesity” journals. As social justice advocates, a social work presence on these boards could help support a discourse shift around “obesity” to one that supports weight-inclusive care and prioritizes eradicating fatphobic rhetoric rather than counterproductively examining ways in which body size can be “fixed” to avoid this distress.
Social workers can also become involved in the development of practice guidelines related to weight within the mental health field. In the public comments on the American Psychological Association’s (2017) most recent treatment guidelines for “obesity,” only one of the individuals protesting the stigmatizing nature inherent in the association’s guidelines identified as a social worker. More social justice–oriented voices in the future structuring of these guidelines could contribute to a necessary shift in the mental health care community’s perspective on weight.
Finally, as previously mentioned, NASW has not amended its own practice update guidelines regarding such matters since 2009. Taking an explicit stance against fatphobia and for size-inclusive, nonstigmatizing care would not only set social workers apart from other mental health care professionals but also position us as the mental health care leaders in this movement. The pursuit of social justice is part of what sets social workers apart from other mental health care professions. It is therefore our responsibility to use this unique perspective to step up as leaders in the anti-fatphobia movement and be part of changing mental health care discourses surrounding large bodies.
Measures of her physical health have also stabilized. Amy reports that since this reframing, she has felt more peaceful and easeful than at any other period in her life, even when compared with periods when her weight was deemed “acceptable.”
*Name and identifying information has been changed.
A note on language: Historically often used derogatorily, the term “fat” has been reclaimed by many large-bodied individuals as a neutral term for describing body size. However, as someone who does not live in a large body, it is not my place to claim use of this word. For that reason, I’ve used the descriptor “large bodied” instead. I intentionally did not use the term “larger bodied,” as to do so would imply a correct or standard body size, thereby inherently othering different body sizes.
Additionally, for many individuals in the anti-fatphobia movement, “obesity” is considered a stigmatizing word, also laden with the implication of derogatory commentary. However, it is also a term that is used widely within the research. For this reason, while I use the term, I’ve presented it in quotation marks to acknowledge its problematic nature.
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