I received the following e-mail from a blog reader who is a certified sex therapist. Her question is one that I hear from and about therapists of all specialties so I thought I would answer it here. (The quote may be a bit triggering, you can skip the indented text to skip the possible triggering language.)
I’m currently a board-certified sex therapist. My clinical “home” is AASECT – the American Association of Sex Educators, Counselors and Therapists – who do fabulous work and push the envelope mightily when it comes to healthy sexuality. My other clinical home is a local listserve. But there are occasions when these two homes can feel like jails – and being part of a small town community and a small, collegial association means that I’ve been reluctant to take on my colleagues despite occasional, and horrendous, comments that are made, clinicians who make a practice out of weight loss therapy, and awful comments linking obesity and health, and obesity and sexuality.
The frequent comments on both listserves concerning obesity are so distressing – and I’m enraged that folks are practicing so unethically. Here’s one from today…. ” We all know Obesity exists and I don’t see this diagnosis in the DSM. Addiction is prevalent in our society. There are individuals eating too much, gambling too much, drinking too much, shopping and spending too much. All to fill a void or manage emotions.” People who would consider themselves evidence-based clinicians freely throw around screwed up commentary about fatness and I have so far just sat back fuming. I’m struggling both personally and ideologically with this as an issue, and can’t figure out how to proceed to take on my colleagues. I regularly post your blog posts on my center’s Facebook page, cut and paste comments from your blog and put them on my personal FB page to “train” my friends in HAES thinking – but haven’t figured out how to address the issue of my colleagues and their fucked-up thinking. Part of this is that if I piss off people locally, I’ll be ostracized from my local clinical home – a big rural landmass, not many people. My business depends on referrals from local doctors, psychiatrists and other therapists.
I’m rambling – and this in itself will tell you how distressed I am. I don’t know how to address this or where to start.
Let’s talk about the actual issues first and then we’ll talk about the politics.
There are two errors that are likely to be committed here. The first is the same weight/health conflation and stereotyping that we talk about all the time, the second is an issue that when all you have is a hammer, every problem looks like a nail.
I talk a lot about the fact that “ob*sity” is not a physical health diagnosis – it’s simply a ratio of weight and height. By the same token, body size is not a mental health diagnosis. While it’s possible that someone’s body weight may be related to an issue such as binge eating disorder, someone’s body size never ever constitutes a mental health diagnosis.
The people who practice weight loss therapy are engaging in the same mistakes as medical doctors who prescribe weight loss. I find it even more unconscionable coming from a purported mental health specialist who should know better than to set people up for failure and then blame them when they fail (since they are obviously harboring the delusion that they can help people achieve long-term weight loss despite a complete lack of evidence to corroborate the theory and a ton of evidence that people are likely to end up less healthy than when they started from both physical and mental health perspectives.)
In my experience, people who push the idea that obesity should be in the DSM as a diagnosis come in three basic varieties. There are well-intentioned people who want to make sure that everyone who does need mental illness treatment gets that treatment and so try to get it covered by insurance in every way possible. There are people who have bought into the stereotypes and misinformation about fat people and are simply tragically misguided. Finally, there are people who look at us and see dollar signs. Eating Disorder Treatment centers and weight loss practices can be lucrative for-profit businesses, and if obesity is considered a diagnosis then that’s a whole lot more potential customers for them (and just like the diet industry, their solution will lead to weight cycling which leads to repeat clients.)
This is a very simple concept: the belief that you can determine anything based on how someone looks (other than how they look) – is stereotyping at best and, when it’s for the purpose of making a mental or physical health diagnosis it constitutes malpractice. Period. Often when dealing with people of size this behavior is engaged in by people, like therapists, who we really wish knew better – and/or who know better for every group except us.
One issue that can happen with health care practitioners is that their specialty becomes a hammer, so every problem they see is a nail. Remember when Doctor Oz tried to claim that every fat person has heart problems because every fat person on whom he had performed cardiovascular surgery had heart problems? Obviously this logic is flawed because people with good hearts don’t get their chests cracked (and every thin person he performs surgery on also has heart problems, but he does not assume that all thin people have heart problems.)
This is what sometimes happens with therapists – every person of size they see has issues with food. Of course that’s because those people come to them because their practice specializes in helping people who have issues with food. Still, therapists are human and can lose perspective and they are inundated with the same incorrect information about health and weight as everyone else. I once witnessed a conversation where someone tried to explain to a binge eating disorder specialist that I did not have binge eating disorder. Her response was that she was certain that I had BED because, in her experience, people don’t get to be my size without having an eating disorder. The statement is true but the conclusion is false – her experience is completely colored by the fact that it is made up of people who sought her out for her claim that she has expertise is dealing with eating disorders, and I happen to look like those people.
With sex therapists, my biggest concern is a scenario in which someone comes to the therapist because their sex life is being affected by body shame brought on by a culture of fat hatred. If the therapists assumes that their body size indicates a mental illness, then they will become part of the bullying culture, engage in victim blaming, and attempt to solve social stigma by trying to get the stigmatized person to change, rather than helping the person acknowledge and cope with the unfair stigma with which they have to deal. The cure for social stigma is not weight loss. The cure for social stigma is ending social stigma.
Bottom line: There are fat people who have under-eating disorders, there are thin people who have over eating-disorders. There are fat people who have very healthy relationships with food and their are “normal weight” people who have very unhealthy relationships with food. As far as I’m concerned, trying to make a mental health diagnosis by looking at someone indicates gross incompetence.
So those are the basic responses, now let’s quickly talk politics.
There’s not an easy answer here. Each person who wants to fight fat oppression has to decide what/if they are willing to risk to do it. It’s entirely your decision and any decision that you make will be valid. The truth is that in order to succeed at ending fat oppression and weight bullying, many people will have to risk something. Some people will have to risk everything – that’s the nature of revolution – but that person doesn’t have to be you.
Once you decide what you want to risk you can choose what method you think will be likely to succeed and be within your risk tolerance – anything from full on confrontation to doing nothing.
One thing that I’ve found can be successful in a situation where less confrontation is called for, is making the point in the form of a question attached to research – for example: “I was reading this paper by Linda Bacon and Lucy Aphramor that seems well-researched and talks about the lack of research on weight loss efficacy. I know that you offer weight loss in your practice, can you help me understand how your philosophy differs?”
or
“I wanted to get your thoughts on this – I read a lot of blogs written by people of size and one of the things they talk about is their frustration with health professionals making a snap diagnosis based on their body size. They say that it’s stereotyping, that it ignores the fact that mental illnesses have many diagnostic criteria and that body size alone does not constitute a diagnosis, ignores the fact that there are people of all shapes and sizes who experience disordered eating and people of all shapes and sizes who have healthy relationships with food, and that it’s disrespectful to them since they are the best witnesses to their own experience. What do you think?”
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Dances With Fat 
“. . . obesity is not a physical health diagnosis – it’s simply a ratio of weight and height. By the same token, body size is not a mental health diagnosis. While it’s possible that someone’s body weight may be related to an issue such as binge eating disorder, someone’s body size never ever constitutes a mental health diagnosis.”
Yes, yes, and again, yes! Clinicians are subject to forgetting that their samples are biased. When my caseload was almost entirely made up of sex abuse survivors, I found myself giving men in grocery stores with their children the evil eye, as if all men in contact with kids were up to no good! Before that, when I worked largely with children of very, very limited mental capacity, I would meet kids of normal intelligence out in the community and think they were geniuses. We are all subject to that kind of thinking, when in fact, people with BED average only 15 pounds over average weight for their height/gender!
Anyways, I’m sharing this post on my Facebook page. Sex Therapist Lady, if you’re reading this, come Like me so I can come Like you! I, too, work in a small community. All of us who work in little towns need to support each other, and we need as much of each other’s support as we can get. You are a woman after my own heart! And I struggle with the same issues: Am I gonna confront this yet again, today? I fear that it makes me look like a carping harpy and that people will decide I’m a crank and stop listening. So I take breaks. There are some fights I just don’t enter into at all, and then it’s back into the fray on another day.
You hang in there, lady, and stay connected to these other communities–it really helps! For myself, as the American Psychological Association wades into the weight-loss business, I know that I will need people like Ragen more and more to help me keep my sanity.
I have SERIOUS issues with the DSM, as a clinician – incidentally, there really is NO OBJECTIVE way to diagnose. Don’t forget, not long ago, homosexuality was listed in the DSM until the early 1970s. Bullocks to that nonsense. And as a therapist, I’d like to think that most mental health practitioners are well intentioned – but in my experience, I’ve observed otherwise. I will fight alongside you, sex therapist lady, to prevent that word (I hate that word – obesity – what a crock of shit) from entering the DSM.
I am grateful for this blog entry because it really gets to the heart of things for me, but it also opens up some issues I’ve had about HAES/FA but didn’t know how to ask until this post gave them better context.
My biggest obstacle to SA/FA for myself has been the idea that my weight is my “fault” because I did not practice healthy habits for a long time. This then leads me to the stereotypical feeling that I could “fix” my weight if I just tried hard enough, i.e. diet and exercise.
When I say I did not practice healthy habits, I mean I developed a compulsive binge eating disorder which I still struggle with, and I had severe depression starting in my teens which (coupled with the ridicule and psychological warfare I underwent in P.E. in school) caused me to be more sedentary than I wanted or needed to be. Basically, even though I may be genetically predisposed to it based on my family’s size and the fact that I have PCOS, I feel that I am overweight because I spent 15+ years eating crap and not exercising. This leaves me vulnerable to the blame/shame messages that society sends me about my weight – I feel like I can’t defend myself because I did it to myself.
HAES proponents say that weight does not equal health. I see my weight as unhealthy not because of the supposed physical health risks but because I feel it is a manifestation/result of my mental and emotional problems. I feel like I will never know if I was “meant” to be fat because I forced the issue with my choices and “made” myself fat, which obviously makes it difficult to accept myself as I am.
I understand the FA movement is in part a push back against mistreatment and oppression, but is there a difference between being fat-accepting and being pro-fat? I believe in defending my right to decent treatment as a human being, but I struggle with the actual celebration of large size. I can accept other people’s bodies but not my own. I understand that not everyone who is fat has an eating disorder, but I am and I do and I believe they are connected to each other. I don’t see my fat as a natural part of me, I see it as the consequences of mistakes that I am now stuck with.
I am also very curious how people define HAES/FA/SA and how they relate to each other – how would the Venn diagram lay out? I’m sure there is overlap but can you have one without the other and are there separate or even conflicting ideas within the three? I know they are not interchangeable terms, and I remember Ragen explained that HAES was more of a philosophy about life/health choices and FA is more a political movement. Are there proponents of FA who don’t believe in HAES? Does SA mean FA by default?
Any clarification, or advice on how to resolve this inner struggle and better align FA with SA, would be appreciated.
I am in exactly the same place you are, both physically and mentally. I know that my eating disorder has caused my steady weight gain over many years, but that doesn’t mean I need to be ashamed for having a mental illness. Some of it is habitual behavior, but what lies behind and underneath that habitual behavior is a mental disorder. Knowing that, I am (theoretically) free to change the behaviors because I know what brings them on, so I am (again theoretically) free to combat those feelings. It doesn’t always happen this way, but it happens this way now more than it used to, for which I’m grateful. I still screw up and pick foods that my emotions want but my body doesn’t or amounts of food that my emotions want but that is horrible for my body and health. Too often I choose not to move because I don’t want to deal with the hassle of moving my body off the couch because it takes a lot of effort.
For me there is a lot of avoidance technique: If someone else will bring me a glass of water, then I don’t have to face the fact that I am fat by hauling my tush out of the chair. If someone else will make my dinner, then I don’t have to take responsibility for what I choose to eat. Oy.
All that is just to say that you are not alone in those thoughts and feelings. *hugs*
You know, all bodies will over time aquire the marks and scars of life. Fat can be one of those “scars.” I too wonder sometimes what my body would be like today if I had done some things differently. The benefits of hindsight, I guess. But we all stumble in life and do things that damage our bodies or leave marks on them. I think our mistake is that we believe the hype that we are supposed to have and keep perfect, flawless bodies, age and disease notwithstanding. Even when we know better, we still believe down deep that if we do everything “right” time/life can’t leave its mark on us. And if we don’t do everything “right” than it’s all our fault. How terrible that we must suffer from guilt and shame, simply for being an ordinary imperfect, flawed person like everyone else. The shame is even worse when mental/behavioral diseases are involved.
Brilliant.
I don’t have enough background to answer any of what you asked, but one thing came to mind. You mentioned that you have a compulsive binge eating disorder as one of your unhealthy habits. I am very concerned about the way BED is defined, and even the term for it, that the term identifies bingeing as the issue.
Below is a link to an article by Jean Antonello, RN, RD,on her web site. While I sharply disagree with Jean onsome key issues (she believes if people stop restricting, and only eat more nutritious, non-dessert type foods (the sugary ones) most of the time, they will lose weight,which of course has not been proven by any study.) She also thinks being of greater weight is unhealthy, which I also disagree with. However, she is quite brilliant on a number of topics, and one of them is that she believes that there is almost no such thing as emotional “overeating,” as is talked about as part of the cause of BED. She believes that basically all “overeating” is caused by restricting/undereating: that it is physical in nature,that the undereating is primary, (for the purpose of weight control, or being too busy to eat,etc.) and that any overeating is secondary to the primary undereating. Many people who have ever dieted (or not) believe they are not restricting, when in fact, they are. She says, “when the undereating stops for good, the overeating will stop.” Read more here, if you wish. I hope this will allow you to see your eating patterns with more compassion, if this explanation is at all applicable in your situation. My best wishes to you.
Click to access emotional-overeating.pdf
As someone who struggled with undiagnosed anorexia nervosa (eating one meal a day, walking 3-4 miles a day every day) in high school, and being later diagnosed with clinical depression and PCOS, I find the idea of obesity being in the DSM frightening.
I don’t have an eating disorder. I remember one well meaning therapist putting me in an eating disorder group. I left because I felt (a) kind of weird being the only girl in the room who wasn’t actively struggling with bulimia or anorexia and (b) I felt like I was a constant, uncomfortable reminder to these women of what they were terrified of… none of them would trust me at all. My issue wasn’t what they were discussing, and that experience really brought home the notion that my weight isn’t a disorder. It’s my weight. Those women had a disorder; for me to put myself in the same definition was ridiculous.
I think the important thing to bear in mind here is that fat people have sex and thin people have sex. Fat people have hangups about sex and so do thin people. (Go on, try and suggest some kind of random non-statistic like: “50% of people have at least some kind of submission fantasy” at a cocktail party and see how defensive people get. It’s great fun.)
I would like to be shaped differently than I am, less out of self-hatred and more out of the fact that clothes that fit me cost three times as much. It’s hard to feel sexy when the lingerie I have to buy costs $80 – $100 an outfit (if I can find something nice at all), and the size 14s of the world can buy the same outfit for $14.99. That’s sizeism hard at work. That is the world at large telling me that I am not allowed to feel pretty because of my size unless I want to pay the price (metaphorically and literally).
My hangups around intimacy stem from a childhood with physical, mental, and sexual abuse. They stem from a church that told me to be ashamed of my body because I was inherently the root of all evil for being a woman, and flawed without possibility for redemption. They came from twelve years of active bullying in the school system. I was not overweight as a teenager (see top paragraph: I was 5’6″ and 140 lbs in grade 14 and wore a size 14 dress to my prom) although I was made to believe I was by a culture that was looking for some way to make me feel “less than”.
I weigh about 240 now. And some of that is medication, and some of that is giving up on my healthy behaviors out of frustration with an inability to lose weight, and some of that is my metabolism changing, and some of that was defensive eating. But none of that was an eating disorder. None of that was a disease. And I have just as much right to be able to talk frankly about my sexual well being as someone who weighs a hundred pounds less than I do.
Because my brain didn’t gain any weight, and that’s what we’re working to heal.
-Betty-
I think for a lot of people, fat people must have all these stereotypical behaviors because that’s what they see for two reasons: 1.) when a skinny girl eats a hamburger and fries, no one notices, but when a fat girl does, people notice and assume she always eats that way and 2.) a lot of what people get their stereotypes from is media, and the media portrays fat people as always eating. I can’t think of a single show where a fat person is shown eating a regular diet. Even on Mike and Molly, the show with two fat protagonists, both struggle with binge eating. So when a lot of people say “I’ve never seen a fat person who didn’t eat too much” they might be saying “I’ve never seen a fat person [on tv] who wasn’t portrayed as eating too much.”
I am in school for social work and I’m gonna have to look out for that “hammer” problem in the future.
Some people in FA do tend to believe that HAES can become a kind of diet. Fat acceptance is actually a human rights issue…that all people, all sizes, all shapes, all lifestyles, all behaviors…are human & deserve equal rights, equal respect, full access in the world. Most of us do a lot of research & the honest research shows that body size & shape is between 70-80% genetic, that, on AVERAGE, fat people eat no more & no differently than thin people do, fat people are not less healthy than thin people, etc. I don’t have an eating disorder, so I cannot address any of the issues of the people posting above, but it is extremely unlikely that, whatever your behavior, you would have become fat unless you had some genetic propensity to do so. After all, there are a lot of people, perhaps the majority of people, with BED who are thin to average-sized, & a lot of thin people who eat a great deal. But what fat acceptance is about for ME, & what I believe that most of us believe, is that, whether or not you are personally responsible for any part of your weight, you are a human being & you deserve to be treated like a human being. And fat is not an illness, it is a body size.
I personally am from a family of fat people. I have been between solid & sturdy & frankly fat all my life, aside from a couple of years in my mid-20’s when I Kept myself thinner than was ever natural for me through exercise bulimia/food restriction. I have been active all my life & fought to find balance, to be active enough to gain the health benefits of exercise but to stop exercising compulsively. I regained more weight after each bout of compulsive exercise &/or dieting, after bearing my children, still more after my LAST bout of compulsive exercise which ended about 8 years ago, & lastly, a bit more with menopause & aging.
I don’t eat compulsively, but I do eat what I want, as much or as little as I want, &, because I am past 62 years old now & have seen quite a lot of life & of people, of mortality, I am not necessarily a strong believer in the idea that we control our health/how long we live with exercise or by eating a certain way, because life does not come that neatly packaged; many people who do everything right drop dead young, many who do everything wrong live to be very old. I certainly DO believe that people do naturally come in all sizes & shapes, that people of all sizes & shapes can be healthy, but that health is not totally within our control & that it is also not a moral imperative.
And fat bodies are as worthy, as beautiful, as sexy, as deserving of celebration & of being embraced as any other bodies. I have been involved in fat acceptance for 32 years now & I am not apologizing for my body, nor am I looking for a cure for it. I am fine as I am & so are all of you. I wish everyone self-love & peace in his/her natural body.
I wish I’d written this. Outstanding.
Thank you for all your advice. I had to see the doctor today and because of what I have learned I came away with treatments for various things that had be brushed over before or not treated correctly and I’d not bothered to go back because it wasn’t bad enough.
The doctor mentioned weightloss as a possibility but didn’t push it and listened when I said I was tackling my health from a HAES point of view.
Instead of focusing on just one problem she has tackled 3 (2 long term recurring problems and a new one) and had me schedule a follow up appointment for next month to check on how I’m doing.
She did say healthy habits would lead to weight loss (in my case I will probably lose a coupe of stone, but that will still leave me in a BMI category which should come with a cape and secret identity) but she did not push weight loss.
The one thing I did forget to ask about was my blood pressure, but the pharmacist informed me that the soluble anti inflammatory might cause raised blood pressure and since the last time mine was checked I’d taken one not long before I went out and then rushed to the doctor I’m going to be much less stressed about the next test.
As for therapists I’m lucky not to need to see one currently, I probably should have in the past, but I’m now in a place where I really don’t care that some 18 year old idiot wants his mates to know that he really doesn’t want to sleep with the random fat stranger across the road so badly that he has to yell loudly enough for me to hear. My boyfriend wants to sleep with me and that is enough for me. I do find it disturbing that people who are potentially dealing with people who are at their most vulnerable are unwilling to look past preconceive idea.
TRIGGER WARNING: While probably well intentioned this comment contains assumptions about health and ability based on size and language that may be interpreted as fat shaming.
HI Ragen, I love to read your words because there is a lot of truth. As a 265 pound 5ft 4in woman, I have to suffer the indignation of being told things that I know are simply not true about me. My body does function with an everyday ability to walk, ride a bike, swim, breath, sing, blink, laugh, cry, sleep, have sex with my boyfriend, bathing, showering, going to the bathroom and thinking which I do a lot of. I’ve been thinking, about those who weigh a lot more than I do like say over 400 pounds. Doing simple things as I mentioned could be a lot tougher for them like fitting into a car seat or bus seat. I would have to honestly say that getting over say 350 pounds would begin to put a person in possibly an unhealthy category but for sure getting over 400 lbs would make living life difficult. How could it not? Could you please give me your thoughts on this subject. Your friend, Karen
Hi Karen,
I believe that this question is well intentioned and I’m sorry if this seems harsh, but I think that what you are engaging in is exactly what you want people not to do to you. You are making assumptions and guesses about health, ability, etc. based on someone’s size. When you do that, you become the cause of people who are 350 or 400 pounds having to suffer the indignation of being told (by you) things that are simply not true about them.
While I’m leaving this comment here so that I can answer it, I would ask that you realize that I have readers who are well over 350 pounds who do not come here to have to read fat shaming comments about someone their size from someone your size.
You said “I would have to honestly say that getting over say 350 pounds would begin to put a person in possibly an unhealthy category” – that’s precisely the kind of speculation that you are asking people NOT to engage in about you, and it is not backed by evidence – we cannot just make guesses about someone’s health based on their size.
As we talked about a couple of days ago, weight and health are two separate things (https://danceswithfat.wordpress.com/2012/04/22/no-such-thing-as-a-healthy-weight/) There are people at 400+ pounds who do all the things that you do (and probably more) – the walking, biking, swimming, having sex etc. etc. – just like your body is used to holding up 265 pounds (which people who weigh half of what you do might think is impossible), their bodies are used to holding up their weight.
Besides which, since there is very little chance of anyone changing the body size, everyone can only do the best they can with what they have where they are and nothing good comes from speculating about other people’s bodies based on their size – it’s stereotyping pure and simple. If things do not fit someone, that is a problem with the things, not the person. It’s not different whether the person weighs 150lbs, 265lbs or 400lbs. Your comment could be read as insinuating that your body size is ok, but that someone else’s is not and that is simply not ok.
I hope this makes sense to you.
~Ragen
Karen, as someone who is in what you have decided is an “unhealthy” size range, I have to tell you a few things:
As a 370 pound 5ft 4in woman, I have to suffer the indignation of being told things that I know are simply not true about me. My body does function with an everyday ability to walk, ride a bike, swim, breathe, sing, blink, laugh, cry, sleep, have sex (though I don’t currently have a boyfriend), bathe, shower, go to the bathroom and think, which I do a lot. I’ve been thinking about those who weigh a lot less than I do, like say around 250 pounds and how sad it makes me that even they – who are oppressed by society at large (no pun intended) choose to turn prejudicial and bigoted thoughts in my direction without knowing anything about me other than my body size. I would have to honestly say that their judgment is as oppressive to me just as much as society’s judgment is oppressive to them. How could it not be?
Do you get it?
Just to be clear, I did not turn your words back on you to hurt you, but so that you could see that I can do all the same things at my size that you can at yours. The point was to to help you see that your thoughts about those fatter than you are the very same thoughts that society thinks about you. Oppression is oppression. You can’t sit back and not want to be oppressed yourself at the same time you are presenting oppressive judgments to others.
Thanks, Helena, that was great. It hits home with me because some years back, that could have been me, thinking being somewhat fat was okay, but REALLY fat was bad, unhealthy, etc. We all live & learn, I know I certainly have, You are so right; oppression is oppression, whether your oppressor is thin or another fat person. I am also disabled, so with me, there was a double whammy in realizing that I was treated people the same way others treated me.
I’ve had that “come to Jesus” moment where I realized what I was doing was what I didn’t want done to me. The rationalizations of why it was OK for ME but not THEM rang hollow in my ears after that and I had no choice but to step up and say, “If it’s not OK for them to do that to me, then it’s not OK for me to do that to someone else.” I think that’s often how the cycle of oppression self-propagates. We feel crappy because someone oppresses us, so we turn around and do it to someone else to make ourselves feel worthier. ><
Basic “GOLDEN RULE” stuff – something schools used to teach kids, but have since stopped.
I had it taught to me, but it just didn’t dawn on me what I was doing. It took a moment of clarity to get that.
I have been a normal weight person with binge eating disorder. I have also been an obese person with no eating disorder. The two do not always go together.
What’s really hysterically funny (not) is that I developed the binge eating disorder through dieting, i.e. attempting to get rid of what this person describes as an eating disorder (obesity).