4 Ways Fat People Need to Be Included in Reproductive Justice

A person has their head on their folded arms, resting over a ledge with a sad expression.

A person has their head resting on their folded arms, leaning over a ledge with a sad expression.

Going to see the doctor has always been nerve wracking.

Since I was a child, doctors have made disparaging remarks about my weight right in front of me.  When I was eight years old, a doctor told my mother that my food allergies must be “working in reverse” because I was “so fat.” Then he laughed.

It’s been more or less a parade of humiliating and infuriating incidents ever since.

Any fat person can tell you that finding a doctor that will listen to us or take our problems seriously is a total crapshoot. No matter the issue, we’re told to lose weight. Sprained your ankle? Lose weight. Ear infection? Lose weight. Flu? Lose weight.

Didn’t you know that thin people never get ear infections or the flu?

It’s probably not surprising that a lot of fat people tend to avoid the doctor as much as they can. I know I’m guilty of waiting until the symptoms are unbearable (and a little beyond) to make an appointment.

But there really isn’t anything much worse than a gynecologist who hates fat people.

My former gyno gave me a humiliating lecture about how awful and fat I was in the middle of a pelvic exam. In a position in which anyone would feel uncomfortable and powerless, I was subjected to non-stop vicious comments about my weight and “food addiction.” She interrogated me about what I ate while doing the Pap smear, and when I replied, she called me a liar.

I was in tears by the time the exam was over. I felt violated and humiliated. And I didn’t go back to the gynecologist for over four years.

Medical disrespect and discrimination is not news to fat people. This is a common topic within fat activist circles. But I don’t see the harm and violence that’s caused by fatphobia being discussed in other activist circles.

People love a confident fat girl wearing what she wants, but they don’t really want to hear about the ways in which our lives are limited and harmed by fatphobia.

It’s time for that to end.

Reproductive rights are the heart of feminism because without the ability to control when and if and how we have children, we would not be able to participate in politics, the workplace, or the wider public sphere.

When we’re denied our right to choose, we’re denied our humanity on the most basic level. If we don’t have those rights, we don’t have anything.

Yet, fat people are being denied the right to choose in ways that have been invisible to the larger feminist movement. Fatphobia’s impact on fat people’s ability to control their reproduction is a topic feminism has yet to address.

But I believe in the power of feminism, and I believe we can take this issue on, and in doing so, start to understand reproductive justice in a more nuanced and intersectional way.

Feminists need to acknowledge the discrimination against fat people and to treat those issues as important. Our lives are real, and we are worthwhile.

1. Emergency Contraception and Hormonal Birth Control

In November of 2013, news broke that the emergency contraception Plan B may begin to lose effectiveness in people over 166 pounds and may not be effective at all for people over 176 pounds.

As such, a European manufacturer of emergency contraception using the same hormones as Plan B added a warning label about weight restrictions. Pundits and reporters asked whether the FDA would require a label change in the US.

In July 2014, the European Medicines Agency reversed its labeling decision, stating that there wasn’t enough evidence to conclude that higher body weight has a negative effect on emergency contraception. The agency didn’t consider the two studies that had been conducted enough evidence to warrant the warning in the first place. 

We need more studies to determine with more certainty whether progestin-only emergency birth control (like Plan B) has a hard weight limit and whether the dosage should be different for people over that limit. But it doesn’t appear that this research is being done.

The warning label was retracted, and this story sank like a stone. People will tell you that there aren’t any weight restrictions because they believe that the warning was completely retracted, which simply isn’t true.

This is a huge problem because Plan B is the only emergency birth control that is available over the counter in the US, and it costs fifty dollars per pill. Fifty dollars is a lot of money for something that may or may not work.

This issue leads to a series of questions: Why didn’t the original testing of this medicine include people with a wider variety of body sizes to better reflect the actual population who would be using it?

The average weight of an American woman is 166 pounds, so we’re left with a form of emergency birth control that may not be effective for a large proportion of the people who need it.

Plan B was originally approved in 1999, but we didn’t hear until 2014 that there might be an issue for people with higher body weights. When is this additional testing going to be done, and why hasn’t there been any pressure to follow up with the FDA and the pharmaceutical companies to make sure that these tests are done?

Fat people are, on average, poorer than thin people and less able to access medical care, so an expensive emergency birth control pill that may not even work for fat people is a cruel joke. 

Even non-emergency hormonal birth control is given in doses that are meant for smaller people and are not adjusted for heavier people.

Some studies have shown that among people taking birth control, fat people have twice the rate of unintended pregnancies as thin people. While results in this area have been mixed, weight may be a factor in hormonal birth control failure.

There is a harmful and untrue stereotype that fat people are not loved or desired.

When our culture sells us this stereotype, it’s easy to treat fat people’s need for birth control as unimportant. That is fatphobia in action.

Fat people have to have a reasonable expectation that their birth control will be effective. If the hormonal birth control currently available is problematic for larger people, they need to know that, so they can make an informed choice about what types of birth control to use.

Access to birth control that may not work isn’t actually access.

Every feminist fighting for expanded access to birth control should also be fighting to make sure that birth control works for everyone.

2. Abortion and Weight Restrictions

A study surveying abortion providers found that 85% characterized providing abortions to fat people as “challenging” and some had implemented policies requiring a “weight fee.”

Patients surveyed indicated that their weight was a factor in delaying their access to abortion because they had trouble finding someone willing to perform an abortion on a fat body. This tracks with anecdotal evidence that fat people have been denied abortions due to their weight.

Another study showed that there wasn’t a significant difference in complication rates for fat people versus thin people in second trimester surgical abortions. And this study presents the same finding.

It explicitly recommends not referring fat people to a high-risk abortion center, because such a referral will lead to delay in accessing an abortion. Delaying abortion increases the risk of complications, increases the cost of abortion, and limits access.

Perhaps the reason some doctors find performing abortions on fat people more complicated is that they refuse to practice their skills on fat people.

A larger body size is presented as a limiting factor in many types of medical treatment; however, children’s smaller body sizes can also make treating them more challenging. But somehow we manage to accommodate their bodies without demanding they grow into an average, easier size before receiving medical care.

The perception of the difficulty of performing abortions on fat people has led to an increased difficulty of access for fat people that isn’t warranted by the evidence. This perception is a symptom of the fatphobia that is common among medical professionals, and it has real and devastating consequences.

If feminists care about making sure every single person who needs and wants an abortion has access to one, then they need to fight against weight restrictions on abortion.

It is no more acceptable to tell someone to lose weight to access their fundamental rights than it is to tell them to drive to another state.

3. How Medical Fatphobia Leads to Fat People Not Getting Reproductive Care

Fat people are less likely to get pap smears or mammograms, even though they’re at a higher risk for developing cancer.

In one study, 17% of doctors reported reluctance to provide pelvic exams to very fat people, and 83% said they would be reluctant if the fat patient demonstrated reluctance.

Everyone is at least a little reluctant to get a pap smear – they kind of suck to get – but thin people aren’t being denied this very basic form of health care because of perceived reluctance.

Fat people face hostile and disrespectful medical staff, which is a huge barrier to care. 24% of nurses in one study were willing to admit that they found fat people repulsive. In a study of implicit biases, medical professionals associated being fat with being “lazy, stupid, and worthless.”

Even if doctors and nurses think they’re covering up their disgust of fat people, they do a terrible job of it. How interested can they be in the health and well being of the non-people they consider stupid and worthless?

When you add in the lack of appropriately sized gowns and equipment and the never-ending parade of condescending and humiliating lectures – often while patients are naked – is it any wonder that fat people avoid the gynecologist?

It would almost be grimly amusing that fat people are blamed for their elevated rates of cancer while also being denied access to cancer screenings – except it isn’t, because cancer kills people.

In this fat-hating culture, any health issues that affect fat people are always presumed to be caused by their size, not by the failure of a health care system that classifies their very existence as an epidemic.

People love to lecture fat people about their health, but they never seem concerned that we can’t get access to decent medical care. It’s almost like that concern isn’t real, but rather, just a tool used to further punish and marginalize us.

In order for feminism to be intersectional when it comes to body size, there has to be real support for fat activists fighting against medical discrimination.

Medical fatphobia is physically and mentally damaging, and sometimes it kills us. We are fighting for our lives, and we need help.

4. Denial of Fertility Treatments and Adoption

Reproductive rights are not only about the ability to delay or prevent child bearing. They also extend to the right to have the same opportunity to bear and raise a child as any other person.

And sadly, fat people don’t always have access to that right either.

Several countries, including the UK and Australia, have informal weight limits on in-country adoption, while Korea and China have explicit weight limits for adoption by non-citizens.

Why not let fat people adopt?

Many of the reasons given for these bans are factually wrong, like the idea that fat people don’t live as long as thin people or that a fat body is a sign that someone is inherently unhealthy. Other reasons are hateful and insulting, like the notion that a fat body is an indication of “unhealthy” emotions or mental illness, which is fatphobic and discriminates against people with mental illnesses.

It seems that people are deathly afraid that fat parents will somehow teach their adopted children to be fat, which is not a thing.

Some people would rather a child grow up and age out of foster care without a parent than allow them to be adopted into a loving and stable home with fat parents. Unfortunately, some of those people seem to be in charge of deciding who gets to adopt and who doesn’t.

People have also reported being denied access to fertility treatments, specifically in vitro fertilization, because of their weight.

The UK, Hong Kong, and New Zealand have already instituted weight limits on fertility treatments, despite studies showing that there is no correlation between weight and rate of live births for IVF. And while there is a higher rate of complications, it’s not statistically significant.

Keep in mind that there are no age limits for IVF, even though maternal age is the most significant factor in unsuccessful IVF outcomes.

When fat people do become pregnant and give birth, they’re more likely to be treated with disrespect by medical staff and pressured into cesareans – at a rate of 50% surgical births in fat people versus vaginal births.  The rate of cesareans in the total population of all births in the US in 2014 was 32%.

And that’s not even getting into the fat-hating disaster of fat children being removed from their homes by the state. Any child of even moderate chubbiness provokes a total screaming panic, as does the idea of leaving a child alone with fat people to be taught how to be fat.

People are willing to do just about anything to make sure that doesn’t happen, up to and including separating families and abusing children. 

Adoption and fertility treatments are already a slow and extremely difficult process, but fat people face additional hurdles that thin people don’t have to face and probably can’t imagine.

Placing obstacles in the way of fat parents or prospective parents is a part of a society focused on punishing fat people, making us invisible, and limiting our rights, all in service of rhetoric that seeks to “solve” the problem of fat people existing at all.

Feminism has a role to play in making sure everyone has the same ability to bear and raise children. When fat people are denied that ability, our essential rights are being denied.

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I want to see feminism address the reproductive rights of fat people and the specific ways their needs are not being met.

I want to see a push for studies and medical training to include the full diversity of body sizes – including fat bodies – that the treatments will be applied to.

I want to see a demand for research to clarify the Plan B issue. Researchers are beginning to study different ways to dose hormonal birth control pills for fat people, but the issue needs more attention. Birth control has to work for everyone, regardless of their size.

I want to see an outcry against weight restrictions on abortion that put fat people at risk of being forced to give birth.

I want fat people to have access to adoption and IVF, and to be able to raise their children in peace and security.

There should be a loud and continued outrage from feminists against the discrimination fat people experience from their doctors.

Thin feminists don’t want people taking away their body autonomy and their choices. Well, neither do we. We want you to care about our rights, and not tell us we have to lose weight to look more like you before you’ll care.

Bodily autonomy applies to fat bodies, too.

And, most of all, I want feminists to see how fat people are mistreated in ways thin people are not, even if that truth makes them uncomfortable.

Stop talking over fat people. Uplift the voices of the fat activists who do this difficult work every day. Don’t think you are an expert on the issues fat people face. We are the experts. Listen to us. 

I want to see feminism take up the issue of fat rights as an intersection of discrimination and to join us in demanding change.

Ali Thompson is a fat activist, artist, and writer from Philadelphia who lives with a partner whose love and support makes that work possible. She runs Ok2BeFat, a radically fat positive website that tells fat people that it’s okay to be who they are. You can find her on Twitter @Artists_Ali.