Industry Voices: Weight Is a Social Justice Issue
By Brianna Clark, LMSW
Social Work Today
Vol. 21 No. 2 P. 5

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.

Anti-Fat Bias
Weight-based discrimination is the fourth most common form of discrimination (Harker, 2015). A doctor prescribing weight loss to someone with a history of anorexic behaviors may sound shocking, but Amy meets the medical criteria for “obesity.” For her and others with similar bodies such an encounter is a regular experience. The fear of facing anti-fat bias in the doctor’s office is one of the many reasons why experiencing weight stigma is an independent risk factor for many physical health diagnoses, including those historically assigned to weight itself (Hunger et al., 2015; Phelan et al., 2015).

Experiencing weight stigma and suffering its ill effects is not confined to the realm of physical health. Predictably, it also has mental health consequences. Experiencing weight stigma is associated with body image dissatisfaction, depression, disordered eating, and psychological distress (Emmer et al., 2019).

Despite its negative consequences on the well-being of clients, the social work profession is not immune to engaging in anti-fat bias. To the contrary, in the growing anti-fatphobia movement working to counteract weight-based discrimination and related stigma, the social work profession is largely absent from the conversation (Friedman, 2012; Scott, 2017). This absence is striking considering social workers have often been at the forefront of social justice initiatives.

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
Not only has the social work profession unwittingly perpetuated fatphobia, it has done so explicitly. NASW’s most recent practice guidelines regarding “obesity” are more than 10 years old, and, while it makes useful points regarding disparate access to food, it uses stigmatizing language that frames “obesity” as something to be “fixed” and “managed,” thereby othering large bodies (Collins, 2009). This framing perpetuates the inaccurate and harmful personal responsibility rhetoric surrounding weight and health (Blundell et al., 2017; Godziewski, 2020). The practice update does not mention the distress caused by weight stigma and discrimination, nor does it acknowledge the extent to which the update’s framing perpetuates this very stigma.

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.

As a result, Panzer’s call for social workers to support weight loss efforts by addressing the comorbid psychological disorders fails to acknowledge the extent to which such a framing reinforces the very stigma associated with their initially presenting psychological distress.

A more evidence-based and socially just role for social workers in addressing “obesity” would be developing an awareness and discourse surrounding the plethora of evidence demonstrating that pathologizing body size, particularly in children, is harmful (Pont et al., 2017). Counterarguments to the anti-fatphobia perspective argue that we should be supportive of individuals who wish to pursue weight loss and healthier lifestyles. However, supporting a client who wishes to lose weight is not the issue. Instead, we must differentiate weight from health, not make the pursuit of health or weight loss a requirement for nonstigmatizing treatment, and acknowledge, validate, and proactively work to eradicate the distress our large-bodied clients experience on a daily basis.

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
The anti-fatphobia movement proposes that a more effective, systemic solution is a larger social justice movement designed to eradicate and protect people from weight stigma, fatphobia, and weight-based discrimination. Such an approach would be more health-supportive than the current fatphobic framing claims to be.

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.

Changing Amy
After an entire lifetime of trying to “correct” her “problematic” body, including attending Weight Watchers meetings as a child, completing bariatric surgery, and years of anorexic behaviors, Amy and I have used the HAES® framework to raise her consciousness surrounding fatphobia and help shift her focus from weight “correction” to more health-supportive approaches. She has since experienced a significant decrease in eating disordered behaviors, negative body image, and other related symptoms.

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.”

When we abandon weight-stigmatizing rhetoric, positive outcomes, like those Amy is experiencing, are possible for our large-bodied clients.

— Brianna Clark, LMSW, is a social worker, psychotherapist, and certified intuitive eating counselor. She is passionate about bringing the Health at Every Size® perspective to mental health contexts. Learn more about Clark and the work she does at bodygrace.org.

*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.

References
American Psychological Association. (2017, September 5–November 5). Public comments on draft version of guideline and panel’s responses to comments. American Psychological Association. https://www.apa.org/about/offices/directorates/guidelines/obesity-guideline-comments.pdf

Bacon, L., & Aphramor, L. (2014). Body respect: What conventional health books get wrong, leave out, and just plain fail to understand about weight. Benbella Books.

Blundell, J. E., Baker, J. L., Boyland, E., Blaak, E., Charzewska, J., de Henauw, S., Frühbeck, G., Gonzalez-Gross, M., Hebebrand, J., Holm, L., Kriaucioniene, V., Lissner, L., Oppert, J. M., Schindler, K., Silva, A. L., & Woodward, E. (2017). Variations in the prevalence of obesity among european countries, and a consideration of possible causes. Obesity Facts, 10(1), 25–37. https://doi.org/10.1159/000455952

Bordo, S. (2013). Not just “a White girl’s thing”: The changing face of food and body image problems. In C. Counihan & P. van Esterik (Eds.), Food and culture: A reader (pp. 265-275). Routledge.

Collins, S. (2009, December). The childhood obesity epidemic: The social work response. National Association of Social Workers. https://www.socialworkers.org/assets/secured/documents/practice/health/childhood
%20obesity%20practice%20update.pdf

Emmer, C., Bosnjak, M., & Mata, J. (2019). The association between weight stigma and mental health: A meta-analysis. Obesity Reviews, 21(1), 1-13. https://doi.org/10.1111/obr.12935

Feister, K. J. (2012). Exploring the relationship of personal factors with explicit attitudes of licensed counselors toward obese individuals. OhioLINK. http://rave.ohiolink.edu/etdc/view?acc_num=osu1353416451

Forristal, K. M. (2018). Fatphobia and clinical counseling decision making in counselor education students. OhioLINK. http://rave.ohiolink.edu/etdc/view?acc_num=toledo1533206025226826

Friedman, M. (2012). Fat is a social work issue: Fat bodies, moral regulation, and the history of social work. Intersectionalities: A Global Journal of Social Work Analysis, Research, Polity, and Practice, 1, 53-69.

Friedman, M. (2015). Mother blame, fat shame, and moral panic: “Obesity” and child welfare. Fat Studies: An Interdisciplinary Journal of Body Weight and Society, 4(1), 14-27. https://doi.org/10.1080/21604851.2014.927209

Godziewski, C. (2020, April 14). Obesity strategy: policies placing responsibility on individuals don’t work – so why does the government keep using them? The Conversation. https://theconversation.com/obesity-strategy-policies-placing-responsibility-on-individuals-dont-work-so-why-does-the-government-keep-using-them-144310

HAES® Community. (n.d.). https://haescommunity.com/search/

Harker, Y. S. (2015). Fat rights and fat discrimination: An annotated bibliography. CUNY Academic Works. https://academicworks.cuny.edu/cgi/viewcontent.cgi?article=1095&context=cl_pubs

Harrison, C. (2019). Anti-diet: Reclaim your time, money, well-being, and happiness through intuitive eating. Hachette Book Group.

Hunger, J. M., Major, B., Blodorn, A., & Miller, C. T. (2015). Weighed down by stigma: How weight-based social identity threat contributes to weight gain and poor health. Social and Personality Psychology Compass, 9(6), 255-268. https://doi.org/10.1111/spc3.12172

Hunger, J. M., Smith, J. P., & Tomiyama, A. J. (2020). An evidence-based rationale for adopting weight-inclusive health policy. Social Issues and Policy Review, (14)1, 73-107. https://doi.org/10.1111/sipr.12062

Lawrence, S., Abel, E.M., Stewart, C., & Dziuban, C. (2019). Social work students’ perceptions of obesity. Social Work Education, 38, 377-391.

Logel, C., Stinson, D.A., & Brochu, P.M. (2015). Weight-loss is not the answer: A well-being solution to the “obesity problem.” Social and Personality Psychology Compass, 9(12), 678-695. https://doi.org/10.1111/spc3.12223

McHugh, M. C. & Chrysler, J. (2019). Making space for every body: Ending sizeism in psychotherapy and training. Women & Therapy, 42(1-2), 7-21. https://doi.org/10.1080/02703149.2018.1524062

Panzer, B. (2020). Childhood obesity: Social work and the epidemic. Social Work Advocates, Feb-Mar 2020, 8-9.

Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & van Ryn, M. (2015). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews : An Official Journal of the International Association for the Study of Obesity, 16(4), 319-326. https://doi.org/10.1111/obr.12266

Pont, S. J., Puhl, R., Cook, S. R., & Slusser, W. (2017). Stigma experienced by children and adolescents with obesity. Pediatrics, 140(7), 1-11. https://doi.org/10.1542/peds.2017-3034

Scott, M. V. (2017, September 2). Where are the voices of social workers in the sizeism conversation? Medium. https://medium.com/@michellevscott/where-are-the-voices-of-social-workers-in-the-sizeism-conversation-f83cade4298c

Shinan-Altman, S. (2017). Medical social workers’ perceptions of obesity. Journal of Social Work, 17, 343-357. https://doi.org/10.1177/1468017316644696

Sonneville, K. R., & Lipson, S. K. (2018). Disparities in eating disorder diagnosis and treatment according to weight status, race/ethnicity, socioeconomic background, and sex among college students. International Journal of Eating Disorders, 51(6),518-526. https://doi.org/10.1002/eat.22846

Warren, C. S. (2019, May 13). Women’s experiences of weight stigma and sizeism in therapy. Psychology Today. https://www.psychologytoday.com/us/blog/naked-truth/201905/women-s-experiences-weight-stigma-and-sizeism-in-therapy