Weight Stigma and Reproductive Health Care

by Shay Upadhyay

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All people, regardless of body shapes and types, deserve non-judgmental medical treatment and care that compassionately supports their life decisions. Unfortunately, this is not the reality for many people who identify as fat or obese. Stories of medical discrimination against people who are considered fat, obese, and/or overweight are widespread in the United States. Patients who are overweight may be subjected to condescending lectures from their doctors about losing weight, no matter the type of medical screening. People who identify as fat or obese are more reluctant to go to the doctor for these reasons.

One-third of reproductive-aged women in the U.S. are obese, which can be defined as having a body mass index (BMI) of 30 or greater. Despite high numbers of obesity in this country (that are only increasing due to the COVID-19 pandemic) the reproductive needs of people who are obese are often ignored due to weight stigma in the medical community. This results in a lack of access to abortion care, effective emergency contraception, and comprehensive reproductive healthcare for people who are obese. What’s more, the fat shaming and gaslighting that occurs in the medical sphere often ignore the larger, systemic issues that impact the health of Americans, including a livable wage, safe neighborhoods, and access to healthy, affordable food and health care.

What is Weight Stigma?

As defined by the National Eating Disorders Association, “weight stigma” (also referred to as “weight bias” and “weight-based discrimination”) ​​is discrimination or stereotyping based on a person’s weight. The presence of institutional and internalized weight stigma among medical professionals often leads to people who are obese not having access to comprehensive reproductive care they deserve.

Access to Reproductive Care

There are several weight-related barriers, like equipment and gowns that cannot accommodate overweight people, that make going to the doctor a difficult experience for people with a high BMI. While the American Medical Association (AMA) has officially recognized obesity as a chronic disease, medical professionals often overlook the environmental, cultural, and genetic factors that impact weight. According to the Centers for Disease Control and Prevention (CDC), behavior, environment, and genetic factors all have a role in causing people to be overweight and obese. Eating healthy is expensive on a limited food budget. That being said, not everyone wants to eat healthy either, and that is their choice. Regardless of lifestyle choices, individuals deserve comprehensive health care when they go to the doctor. The doctor’s office is one of the most vulnerable places you can be and people do not deserve to be fat-shamed for their personal choices regarding health. Instead, doctors should provide life-affirming care and offer healthy alternatives that meet patients’ needs.

There is evidence to support that doctors do not offer the same quality of reproductive care to people that are obese. Even though women who are obese are at higher risk for cancer, studies show that doctors are less likely to give women who are obese the recommended cancer screenings or examinations, especially if the patient shows reluctance to receiving such care. The presence of weight stigma in the medical community has created a narrative that obese bodies are more “risky” to care for. In a study examining the differences in frequency of pelvic screening examinations between obese and non-obese women and the effect of physician and patient attitudes toward obesity on examination frequency, it was found that 17% of physicians were reluctant to perform pelvic examinations and 83% of physicians were reluctant to perform pelvic examinations on patients who were reluctant to receive them.

Polycystic Ovary Syndrome (PCOS) is associated with reproductive challenges including difficulty in conceiving and pregnancy-related complications of miscarriage, hypertensive disorders, gestational diabetes, and prematurity. Between 38% and 88% of women who are obese also have PCOS. For women who are obese, doctors often recommend weight loss as the first solution to conceive, but it is important to recognize the many other factors that can impact infertility. At NARAL Pro-Choice Maryland, we believe people know their bodies the best. Doctors must respect patient autonomy while offering their expertise in a compassionate and non-judgmental way.

The absence of medical attention for people who are obese is mentally and physically harmful. Medical training must address weight bias. Family planning providers should ensure that their facilities have the appropriate equipment, including appropriately-sized blood pressure cuffs and hospital gowns, to meet the needs of patients with a high BMI. Medical professionals must improve their office environments and increase their capacity and sensitivity to the needs of patients who are obese to improve the quality of their healthcare experience.

Access to Reproductive Care Procedures and Services

Pregnant people who are obese may be denied certain reproductive care procedures and services due to concerns about medical risk or lack of necessary equipment at the medical provider. Examples of such services include abortion care, in-vitro-fertilization (IVF), and labor and delivery.

Some medical providers will deny abortion care and I.V.F. services to people above a certain BMI cutoff number even though the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology has not yet established guidelines on whether treatment should be declined based on weight. I.V.F. providers will sometimes deny care to people who are obese because doctors may not be able to retrieve eggs through the vagina and have to instead go through the abdomen, thus lowering the chances of the patient becoming pregnant.

At MD NARAL, we know that delaying an abortion only increases cost of the abortion, adds to emotional distress, and limits access to abortion providers. However, abortion is only one area in the wide scope of reproductive health care. Being truly responsive to the needs of individuals who are pregnant or who are seeking to become pregnant means being committed to accommodating people of all body types.

Access to Effective Emergency Contraception

Emergency contraception has been around since the 1970s, but people who are obese still do not have access to effective over-the-counter emergency contraception. Between the years 2006 and 2010, it was reported that 5.8 million American women used emergency contraceptive pills. It was only until 2013 that the CDC released a report with weight data suggesting that popular over-the-counter emergency contraceptive pills like Plan B-One Step© would not be effective for women weighing above 166 pounds. At the time, Plan B One-Step© was the only emergency contraceptive in the United States that was available to women of all ages without a prescription.

While additional brands and options of over-the-counter and prescription emergency contraceptives have become available in the past several years, there is still little information proving these contraceptives are effective for people who weigh above 170 pounds. In 2016, the CDC published research stating that over-the-counter emergency contraceptives may not prevent pregnancy as effectively or often for women with a BMI of 30 or greater. Emergency contraception can be expensive, and it is not a good enough answer to just say that people who weigh more than 166 pounds must buy two packs of the medication when the cost is so prohibitive.

Rather than excluding people above a certain weight from accessing emergency contraceptives, we need more information on whether or not the dosage for progestin-only emergency birth control should be different for people who weigh over the amount that makes the drug effective. In the reproductive justice movement, we fight for easy access to birth control. If a large population of this country does not have access to birth control that works for them, our work is not done.

Obesity is considered an epidemic in this country. Instead of fat-shaming people who are obese, we must keep building systems where people can access life-affirming health care and make lifestyle choices that best fit their needs.

Sources

Barber TM, McCarthy MI, Wass JA, Franks S. Obesity and polycystic ovary syndrome. Clin Endocrinol (Oxf). 2006;65:137–145. Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6734597/#bibr2-1179558119874042.

Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. Jama 2010. 2010 Jan 13;303(3):2009.14. Accessed at https://jamanetwork.com/journals/jama/fullarticle/185235.

Friedman, A. M., Hemler, J. R., Rossetti, E., Clemow, L. P., & Ferrante, J. M. (2012). Obese women’s barriers to mammography and pap smear: the possible role of personality. Obesity (Silver Spring, Md.), 20(8), 1611–1617. https://doi.org/10.1038/oby.2012.50.

Adams, C. H., Smith, N. J., Wilbur, D. C., & Grady, K. E. (1993). The relationship of obesity to the frequency of pelvic examinations: do physician and patient attitudes make a difference?. Women & Health, 20(2), 45–57. https://doi.org/10.1300/J013v20n02_04.

The political leader of the pro-choice movement in Maryland.