When New York Times best-selling author Roxane Gay was twelve years old, she was gang-raped. Her then-boyfriend took her on a bicycle ride to an isolated cabin in the woods, where they met some of his friends. He bragged to these friends, and then he pushed her to the ground and raped her as they pinned her down. Then, he helped hold her down by the wrists and spat in her face as his friends followed suit, one by one.
Feeling humiliated and ashamed, Ms. Gay kept this secret throughout her teenage and young adult years. She cites her rape, and her reaction to her rape, as the reason for her subsequent weight gain. She eventually reached 577 pounds.
As a physician who is Board-Certified in Obesity Medicine and has seen over 100,000 urgent care patients, I understand the multifactorial etiology of obesity — the confluence of genetics, epigenetics, behavior, and environment. I am acutely aware of both the need to listen to a patient’s account of any disease process and the need for caution in accepting a patient’s self-assessment.
After reading Ms. Gay’s book Hunger, A Memoir of (my) Body, I agree that her rape was the principal driver of her obesity.
So what does this mean to me as a physician?
I used to believe that if a physician wanted to get a solid grounding in Obesity Medicine, they had to read. Start with Volumes 1 (695 pages) and 2 (496 pages) of Bray’s Handbook of Obesity, follow it with the last two years of the journal Obesity or Nature’s International Journal of Obesity, then review the latest approved medications and new surgical procedures. You now have a good understanding of the basic neurobiology of obesity and will ace your Obesity Medicine Boards, but you’ll have no insight into the human dimension of what it means to be significantly overweight.
To understand what it means to be “fat person” or a “fat woman,” according to Ms. Gay, we would do well to study her book as if it was one of our textbooks. No matter who you are and how you identify yourself, you will learn something about humanity. I certainly did.
You can read this book as a writer’s journey, an account of sexual assault, or a straightforward memoir of a bisexual, black, obese feminist. You can even read this critically from the perspective of an “evidence-based medicine only” physician-scientist.
But I read it from the perspective of a person who has intermittently struggled with my own weight and who also happens to be a doctor, to gain a little insight into my own biases and issues. Here are some of the lessons I learned:
Consider rape or sexual assault as a significant contributing factor in obesity. It’s easy to get wrapped up in theoretical questions about weight contributions from genetics, epigenetics, medications, psychology, environment, and culture. These have value, but if a patient comes in with a BMI of 50, consider and delicately approach the subject of sexual assault in childhood. Ms. Gay had attentive parents who were concerned about her weight, took her to physicians, and spared no expense to help her. But no one asked her, “Were you sexually assaulted as a child?” It was the doctor’s responsibility to draw it out.
We all should look more carefully at our waiting room offices. Are there chairs without arm rests? Are the seats strong enough? Are the aisles wide enough? Overweight people are used to humiliation, but do we have to humiliate them in a doctor’s office too?
Ask patients with obesity what terms they would feel comfortable to discuss their weight. Some people are offended by the term “obese.” Some are offended by the term “fat.” Although the term “with obesity” is appropriate for the medical literature, it may not be appropriate for a patient in your exam room. Here’s an idea: We should talk to our patients about the terminology they prefer. We should also talk about the terminology we require.
People may not want to talk about their weight. Unless it has a direct bearing on what they are being seen for, that is just fine.
Reconsider the policy of weighing everyone every time. Is a specific weight really needed to evaluate a patient for a sinus infection or wrist injury?
Women with obesity are still women. Ms. Gay wrote that at a certain weight, she appeared to lose her gender. She was just seen as fat.
- If I see an internet company that specializes in pretty clothes for women of size, I will invest in it.
- Unless specifically requested, giving dietary advice is always rude.
Overweight people know they are overweight, and they know this is unhealthy. Berating them will not help.
Don’t remove food from people’s shopping carts because they are overweight. (Yes, that actually happens to Ms. Gay.)
People can strive to accept their weight and still want to lose weight. Anyone working consistently with patients with obesity will run across the movements: Fat Acceptance, Size Acceptance, Fat Liberation, Fat Activism, Fatism, Fat Justice, or Fat Power. These always used to irritate me because I felt they were attacking doctors. But I learned from Ms. Gay’s book that body acceptance does not preclude wanting to lose weight and improve health. Body acceptance is about seeing an obese person as a person, and it is our responsibility as professionals to dive into this discussion with an open mind and an open heart.
- The current medical system can often be both ignorant and cruel towards people with obesity.
If you are on a plane next to someone who is significantly overweight, be kind! Pull up the arm rest, or offer them the aisle seat. Look at the world through their eyes. Feel the world through their body. Whatever it takes, be polite.
If you have a patient with obesity, ask them what would make them feel more comfortable in the office, both in that moment and for future reference. Listen, and when possible, act upon their suggestions.
Things that are trivial for many can be physically and emotionally uncomfortable for people with significant obesity. Have you ever gone hiking with 40-pound pack? How did you feel after 6 hours? Now, imagine hiking with a 150-pound pack you can’t remove. Something as simple as getting out of bed in the morning takes on a whole new meaning.
- People are not their BMI.
You won’t regret reading Ms. Gay’s book. My only regret is that I didn’t read a book like this 25 years ago in medical school. I would have become a much better doctor.
Dr. Matthew Rehrl is a physician who has served in a C-Suite advisory role on social media within healthcare for over a decade. His current focus is the ethics of AI in healthcare. He reports no conflict of interest.
He also recommends Roxane Gay’s 7-minute interview with Trevor Noah and her 40-minute Medium Podcast episode about her weight loss surgery this year.