Nearly everyone who is overweight or obese has suffered some form of bias, from disapproving glances and unsolicited advice about how to lose weight to the seemingly unending stream of "fat jokes" and the unflattering and even humiliating portrayal of overweight people in the media. Despite the pervasive anti-fat bias in American culture, until recently there were anecdotal reports, but little evidence, demonstrating that negative attitudes toward obese individuals resulted in stigmatization and clear instances of discrimination.
In "Bias, Discrimination, and Obesity" (Obesity Research, vol. 9, no. 12, December 2001), Rebecca Puhl and Kelly Brownell reviewed data revealing that systematic discrimination against obese individuals occurs in at least three arenas�education, employment, and health care. They also acknowledged that evidence points to discrimination in adoption proceedings, jury selection, and housing.
The authors described obese people as "the last acceptable targets of discrimination" and named rejection�teasing, taunts, derogatory comments, and derision�by peers as the first of many challenges overweight or obese youngsters will face. Some studies have found distinct anti-fat bias in children as young as age three, and increasingly negative stereotypic attitudes with age. Puhl and Brownell point to a landmark study conducted during the 1960s in which children were shown pictures of six children with various physical characteristics and disabilities, including use of crutches or wheelchair, amputations, or facial disfigurements, and were asked to rank them in order of whom they would be most likely to befriend. The majority of subjects ranked the picture of the obese child last. When this study was performed again in 2001, children in the fifth and sixth grade displayed the strongest bias against the obese child and expressed even more prejudice than their counterparts had forty years earlier. Teachers also revealed considerable bias, with nearly 30 percent in one survey describing becoming obese as "the worst possible thing that can happen to a person."
The authors observed that along with the psychological and social consequences of prejudice and exclusion, obese students suffered lower rates of college acceptance, with obese women gaining college admission less frequently (31 percent) than obese male applicants (42 percent). They also found that normal-weight college students received more financial support from their families than overweight students, and overweight women were least likely to receive financial support.
Overweight and obese job applicants and workers may be subjected to weight-based discrimination in employment. Numerous studies have documented discrimination in hiring practices, especially when the positions sought involved public contact, such as sales or
direct customer service. Obese workers face inequities in wages, benefits, and promotions, and several studies have confirmed that the economic penalties are greater for women than for men. Overweight women earn less doing the same work as their normal-weight counterparts and have dimmer prospects for promotion. The courts have considered cases in which workers contended that their job terminations were weight-related. The outcomes of these cases indicate that termination can occur because of employer prejudice and arbitrary weight standards.
Weight Bias among Health Professionals
Anti-fat bias among health-care professionals may discourage obese persons from seeking medical care and compromise the care they receive. Although research has indicated that obese patients often delay or cancel medical appointments for a variety of reasons, including fear about being weighed or undressing in front of health professionals, speculation exists that presumed or real prejudice on the part of health professionals also may deter them from seeking medical care. When researchers asked more than 400 physicians to name patient characteristics that provoked feelings of discomfort, reluctance, or dislike, one-third of the subjects mentioned obesity, making it the fourth most-common condition named after drug addiction, alcoholism, and mental illness. The subjects also linked obesity to negative qualities such as poor hygiene, hostility, dishonesty, and noncompliance with prescribed treatment. Another survey of family physicians found that two-thirds said their obese patients lacked self-control and nearly 40 percent characterized their obese patients as lazy. Nurses expressed similar attitudes�nearly half reported that they were uncomfortable caring for obese patients and 31 percent told surveyors they would prefer not to care for obese patients at all.
Puhl and Brownell found documented evidence that health professionals' deeply held negative stereotypes adversely affected their clinical judgment, diagnosis, and the quality of care delivered to obese patients. A survey of more than 1,200 physicians revealed that most were ambivalent about caring for overweight and obese patients, and did not intervene and treat them with the same determination they displayed toward normal-weight patients. Just 18 percent said they would refer an overweight patient to a weight-loss program and less than half (42 percent) would refer a mildly obese patient to a weight-loss program.
Even health professionals who specialize in the medical treatment of obesity are not immune from anti-fat bias. Marlene Schwartz and her colleagues administered a standardized test that measured bias to 389 health professionals (198 women and 191 men)�physicians, researchers, dieticians, nurses, psychologists and others�who attended an international obesity conference in Quebec in 2001. The researchers reported the test results in "Weight Bias among Health Professionals Specializing in Obesity" (Obesity Research, vol. 11, no. 9, September 2003). Bias was assessed using the Implicit Associations Test (IAT), a timed test that analyzes the automatic associations respondents make about particular attributes. For example, the IAT helps to identify if test-takers hold negative attitudes and stereotypical views about obese people, such as considering them to be lazy, unmotivated, sluggish, or worthless.
The researchers found that the health professionals they tested, one-third of whom provided direct clinical care to obese patients, exhibited significant anti-fat bias. They linked the stereotypes lazy, stupid, and worthless with obese people, with younger health professionals displaying more anti-fat bias than older health-care workers did. The researchers hypothesized that younger health professionals may have been more strongly imprinted with societal pressures to be thin, which have intensified in recent decades. Another explanation may be that older health professionals, who have more maturity and experience, may have overcome some of their negative attitudes about obese patients. Despite the presence of bias, the researchers conceded that while it is intuitively appealing to assume that bias has an influence on treatment, their research did not demonstrate that bias resulted in poorer treatment of obese patients.
Airlines Weigh Their Options
In June 2002 Southwest Airlines became the center of a fiery debate when the airline decided to strengthen its enforcement of a policy established in 1980 of requesting and requiring passengers who, because of excessive girth, must occupy two airplane seats to purchase both seats. The policy allows passengers to be reimbursed for the additional seat if their flight is not full. The National Association to Advance Fat Acceptance (NAAFA), an advocacy group, and other consumer groups termed the move discriminatory. Southwest Airlines is not the only airline with this policy; Continental, Northwest, and other commercial carriers also require large-sized passengers to pay for two seats.
A year later the Federal Aviation Administration (FAA) proposed requiring all passengers on small airlines to be weighed in along with their luggage. The FAA asserted that before take-off, the pilot must calculate the weight of the aircraft as well as that of its passengers, luggage, and crew to determine which seats passengers should occupy to ensure proper balance. For this reason it is vital to know exact passenger and luggage weights on small planes, where several people with a few extra pounds can tilt the plane away from its center of gravity. Although operators of smaller commuter airlines acknowledged the safety issue, they were reluctant to support the
FAA recommendation because they feared that weighing people would discourage them from using commuter airlines, many of which are already strapped financially.
In May 2003 the FAA ruled that airlines must assume that passengers weigh 190 or 195 pounds depending on the season. Similarly, checked bags on domestic flights will rise from an estimated 25 to 30 pounds. The 30-pound estimate for checked bags on international flights remained unchanged. The requirement followed shortly after the crash of a commuter plane that killed all twenty-one people aboard. Investigators suspect the propeller plane was slightly above its maximum weight on takeoff, with most of the weight toward the tail. The weight distribution problem was compounded by a maintenance error that made it difficult to lower the nose with the control column. After the nineteen-seat plane rose above the ground, its nose pointed dangerously skyward; the pilots were unable to level it off, and the plane spun into the ground.
San Francisco Bans Weight-Based Discrimination
On July 26, 2000, the San Francisco Human Rights Commission unanimously approved historic guidelines for implementing a height/weight anti-discrimination law, and the city became the first jurisdiction in the United States to offer guidelines on how to prevent discrimination based on weight or height (Compliance Guidelines to Prohibit Weight and Height Discrimination, San Francisco Administrative Code Chapters 12A, 12B, and 12C and San Francisco Municipal/Police Code Article 33). Santa Cruz, California, Seattle, Washington, Washington, D.C., and the state of Michigan have similar laws banning discrimination based on height or weight.
The strength of the ordinance was tested two years later when Jennifer Portnick, a 240-pound aerobics instructor, was refused a job at Jazzercise, Inc., an international dance-fitness organization based in Carlsbad, California, and brought her case before the San Francisco Human Rights Commission. She later reached an agreement with the company to drop a requirement about the appearance of instructors. It was the first case settled under the San Francisco ordinance, which has become known as the "fat and short law."
Patricia Leigh Brown, in "240 Pounds, Persistent and Jazzercise's Equal" (New York Times, May 7, 2002), reported that Portnick's attorney, Sondra Solovay, the author of Tipping the Scales of Justice: Fighting Weight-Based Discrimination, said Portnick was "geographically lucky" to have filed her case in one of just four jurisdictions in the country that outlawed weight-based discrimination.
Some observers did not celebrate Portnick's victory. In "Fat Law Should Be Repealed" (Ifeminists.com, May 14, 2002), George Getz, press secretary for the Libertarian Party, described Portnick's case and the San Francisco ordinance as "a case of political correctness run amok," and "just one example of the sizable side effects of government regulation." Libertarian Party Executive Director Steve Dasbach characterized the ordinance as "another wacky anti-discrimination law," and an outgrowth of the 1990 Americans with Disabilities Act (ADA), which was intended to protect persons with disabilities from discrimination but has been used to protect and defend workers with controversial "disabilities" such as a dentist fired for fondling his patients, because he had a sexual addiction, and a worker fired for falsifying records, because he had an impulse disorder that prompted him to wrongdoing. (Obesity itself is not considered a disability under the ADA; however, persons with obesity-related disabilities are protected by the landmark legislation. Because the ADA does not specifically include or exclude obese people, the extent of its protection will be determined in litigation.) Dasbach declared that Portnick's win, forcing an aerobics company to employ an overweight instructor, could pave the way for more implausible hiring practices, such as schools forced to hire illiterate teachers.
SHOULD BALLET SCHOOLS DISCRIMINATE?
Although it took longer to settle, the first complaint filed under the San Francisco ordinance alleged that the prestigious San Francisco Ballet School demonstrated size-bias in its rejection of eight-year-old Fredrika Keefer. The aspiring ballerina's mother, Kristy Keefer, said the school discouraged Fredrika from auditioning because she did not have the "physical attributes that the school looks for." When Fredrika was not accepted to the school, her mother was told that Fredrika's height (3 feet, 9 inches) and weight (64 pounds) were an issue�she did not fit the school's published criteria requiring applicants to have "a well-proportioned, slender body."
The school is subject to the San Francisco ordinance because it receives $550,000 annually from the city's "Grants for the Arts" program. Still, the school denied it had any specific written height or weight requirements for students, and said physical appearance is never the sole determining factor when auditioning applicants. In a published interview, the school's attorney, Emily Flynn, said "It is axiomatic to say that ballet training requires certain physical attributes, and the school's admissions process is inherently selective" ("San Francisco Ballet School Faces Allegations of Size Bias," CNN.com, January 2, 2001).
The lawsuit provoked heated debate among feminists, advocates of affirmative action, and members of the professional dance community. In "Counterpunch: Critic's Argument for Heftier Dancers Is Thin" (Los Angeles Times, April 16, 2001), Toni Bentley, a former dancer with the New York City Ballet, asked rhetorically, "Should music students be admitted to the Juilliard School who are tone deaf and to medical schools with C and D grade averages? Should short guys be hired by the NBA? Should
round little girls be admitted to professional ballet schools, thereby being subjected to a competitive discipline for which they are at a disadvantage?" Bentley asserted that "if the arts or sports are to be subjected to affirmative action and lack of discrimination against the untalented and physically inappropriate, then they will cease to exist."
The Origins of Stigma and Bias
Rebecca Puhl and Kelly Brownell have written extensively about the pervasiveness and strength of weight stigma in the United States. In "Psychosocial Origins of Obesity Stigma: Toward Changing a Powerful and Pervasive Bias" (Obesity Reviews, vol. 4, no. 4, 2003), they observed that many people intensely dread the possibility of becoming obese. In one survey, about one-quarter of women and 17 percent of men said they would sacrifice three or more years of their lives to be thin. There are reports of women who choose not to become pregnant because they fear gaining weight and becoming fat. Others smoke cigarettes in an effort to remain thin or reject the advice that they quit smoking because they fear they will gain weight should they quit. This powerful fear of fat, coupled with widespread perceptions that overweight people lack competence, self-control, ambition, intelligence, and attractiveness, create a culture in which it is socially acceptable to hold negative stereotypes about obese individuals and to discriminate against them.
One explanation of the origin of weight stigma is that traditionally Americans believe in self-determination and individualism�people get what they deserve and are responsible for their circumstances. In this context, when overweight is viewed as resulting from controllable behaviors, it is easy to understand that if an individual believes overweight people are to blame for their weight, then they should be stigmatized. Other research findings�that many Americans view life as predictable, with effort and ability inevitably producing the desired outcomes, and the finding that attractive people are deemed good and believed to embody many positive qualities�support this theory. Interestingly, researchers have found that in other countries, the best predictors of anti-fat attitudes were cultural values that held both negative views about fatness and the belief that people are responsible for their life outcomes.
Several other theories about the origins of weight stigma have been proposed. "Conflict theory" suggests that prejudice arises from conflicts of interest between groups and struggles to acquire or retain resources or power. "Social identity theory" posits that groups develop their social identities by comparing themselves to other groups, and designating other groups as inferior. "Integrated threat theory" proposes that stigmatized groups are perceived as a threat. Proponents of this theory suggest that overweight and obese people threaten deeply held cultural values of self-discipline, self-control, moderation, and thinness. Another theory "evolved dispositions theory" proposes that members of a group will be stigmatized if they threaten or undermine group functioning. This evolutionary adaptation may predispose people to shun obese individuals since they are at increased health risk, and may not be able to make sufficient contributions to the group's welfare because of weight-related illness or disability.
Reducing Weight Bias and Stigma
Bethany Teachman and her colleagues wondered if anti-fat bias would be reduced when people were told that an individual's obesity resulted largely from genetic factors rather than as the result of overeating and lack of exercise. The investigators assigned study participants to one of three groups. The first group received no information about the cause of obesity; the second group was given an article asserting that the principal cause of obesity was genetic; and the third group was given an article that attributed the majority of obesity to overeating and lack of physical activity. As the researchers anticipated, the group told that obesity was controllable�resulting from overeating and inactivity�revealed the greatest amount of bias. However, to their surprise, the investigators found that the group informed that obesity was primarily genetic in origin did not have significantly lower levels of bias than either the control group that had received no prior information or the group informed that obesity was caused by overeating and inactivity ("Demonstrations of Implicit Anti-Fat Bias: The Impact of Providing Causal Information and Evoking Empathy," Health Psychology, vol. 22, no. 1, January 2003).
The investigators also wanted to find out whether eliciting empathy for obese persons would significantly reduce negative attitudes. Teachman and her colleagues hypothesized that by sharing written stories about weight-based discrimination with study participants they would feel empathy with the subjects in the stories, which they would then generalize to the entire population of obese persons. While some study participants in the group that read the stories displayed lower bias, the majority did not have lower bias than a control group that had not read the stories of discrimination. The investigators speculated that the stories describing negative evaluations of an obese person might actually have served to reinforce rather than diminish bias.
Puhl and Brownell observe that the increasing prevalence of obesity has not acted to reduce weight bias. They also refute the notion that stigma is necessary to motivate overweight and obese people to lose weight. They reiterated that dieting is not associated with long-term weight loss, regardless of the individual's motivation. Further, stigma has led to discrimination and exerts a harmful influence on health and quality of life. These obesity experts
contend that unless stigma is reduced, obese people will continue to contend with prejudice and discrimination.
Although few studies have evaluated the effectiveness of strategies to reduce weight stigma, a variety of initiatives have produced varying degrees of attitudinal change. These approaches include:
- Educating participants about external uncontrollable causes such as the biological and genetic factors that contribute to obesity.
- Teaching and encouraging young children to practice size acceptance.
- Improving attitudes by combining efforts to elicit empathy with education about the uncontrollable causes of obesity.
- Encouraging direct personal contact with overweight and obese individuals to dispel negative stereotypes.
- Changing individuals' beliefs by exposing them to opposing attitudes and values held by a group that they consider important. This approach is known as "social consensus theory," and relies on the observation that after learning that a group does not share the individuals' beliefs, they are more likely to modify their beliefs to be similar to those expressed by the group they respect or wish to join.
In "Psychosocial Origins of Obesity Stigma: Toward Changing a Powerful and Pervasive Bias," Puhl and Brownell described the results of their experiments using social consensus theory to modify attitudes toward obese people. They conducted experiments with university students in which participants reported their attitudes toward obese people before and after the researchers offered them varying consensus opinions of other students. In one experiment, participants who were told that other students held more favorable attitudes about obese people reported significantly fewer negative attitudes and more positive attitudes about obese people than they had before they learned about the opinions of other students. Further, they also changed their ideas about the causes of obesity, favoring the uncontrollable causes after they were told the other students believed obesity was attributable to these causes.
A second experiment confirmed that the power to alter the participants' beliefs depended on whether the source of the opposing beliefs was an "in-group" or "out-group." Not surprisingly, participants' attitudes toward obese people were more likely to change when the information they were given came from a source they valued�an "in-group." In a third experiment the researchers compared attitudinal change produced by social consensus with other methods to reduce stigma, including one in which participants were given written material about the uncontrollable or controllable causes of obesity. They found that social consensus was as effective as or more effective than any of the other methods they applied. The researchers stated that social consensus theory also offers an explanation about why obese individuals themselves express negative stereotypes�they want to belong to the valued social group, and choose to accept negative stereotypes in order to align with current culture. Further, by accepting prevailing cultural values and beliefs they not only resemble the in-group more closely but also distance themselves from the out-group, where identity and membership are defined by being overweight or obese.
Although Puhl and Brownell consider social consensus a promising approach to reducing weight bias and stigma, they caution that there are many unanswered questions about its widespread utility and effectiveness. They concluded that "an ideal and comprehensive theory of obesity stigma would identify the origins of weight bias, explain why stigma is elicited by obese body types, account for the association between certain negative traits and obesity, and suggest methods for reducing bias. Existing theories do not yet meet all these criteria."
Advocacy Groups Promote Size and Weight Acceptance
People get so many conflicting messages about what is healthy and what is attractive. The same thin celebrities who were being glamorized in recent years are now being airbrushed to look even thinner on magazine covers. That sends a terrible message, both to the celebrities and to the public. Love your body, it's the only one you have. You have to take care of yourself�and that starts with self-esteem.�Allen Steadham, director of the International Size Acceptance Association, in a press release dated July 18, 2003
There is a growing consumer movement that advocates size and weight acceptance with the overarching goal of assisting people to have positive body images at any weight and to achieve health at any size. Nearly all organizations that champion size acceptance characterize preoccupation with dieting and weight loss as unhealthy and unproductive, citing statistics about diet failures, the dangers of "yoyo dieting"�slowed metabolism, increased fat storage, and regained weight�as well as frustration and low self-esteem. The size acceptance movement proposes that it is possible to be fit and fat and that health and beauty are attainable at all weights. It also works to reduce "fat phobia," anti-fat bias, and weight-based discrimination.
In July 2003 the International Size Acceptance Association (ISAA), an organization that promotes size acceptance and aims to end size discrimination throughout the world by means of advocacy and visible, lawful actions, launched the Respect Fitness Health Initiative and Healthy Body Esteem campaigns to provide an alternative to the "diet-of-the-day" pressures and gloom-and-doom predictions about size and weight that assault people every day. The ISAA asserts that people of all sizes can become more fit, and the organization is committed to
helping people of all sizes strive for higher levels of fitness and improve their overall quality of life. Similarly, the organization observes that everyone could benefit from healthier food choices and is committed to helping inform the public about healthy nutrition.
Another group, the Council on Size & Weight Discrimination, Inc., a not-for-profit consumer advocacy organization working to end "sizism," bigotry, and discrimination against people who are heavier than average, focuses its advocacy efforts on affecting changes in medical treatment, job discrimination, and media images. The Council's basic principles were derived from "Tenets of the Nondiet Approach" (Karin Kratina, Dayle Hayes, and Nancy King, Moving Away from Diets: Healing Eating Problems and Exercise Resistance, 2nd edition, [Lake Dallas, TX: Helm Publishing, 2003]) and focus on:
- Total health enhancement and well being, rather than weight loss or achieving a specific "ideal weight."
- Self-acceptance and respect for the diversity of bodies that come in a wide variety of shapes and sizes, rather than the pursuit of an idealized weight at all costs.
- The pleasure of eating well, based on internal cues of hunger and satiety, rather than on external food plan or diets.
- The joy of movement, encouraging all physical activities rather than prescribing a specific routine of regimented exercise.
The National Association to Advance Fat Acceptance (NAAFA) is a nonprofit human rights organization dedicated to eliminating discrimination based on body size and providing people with the "tools for self-empowerment through public education, advocacy, and member support." NAAFA has assumed a proactive role in protesting social prejudice, bias, and discrimination, as well as working with the Federal Trade Commission to stop diet fraud. The organization also seeks to improve legal protection for people who are overweight and obese by educating law-makers and serving as a national legal clearinghouse for attorneys challenging size discrimination.