Health & Wellness / Life

Queer Women and Body Image: Beyond the Numbers

biopic2E. Cabell Hankinson Gathman holds a doctorate in sociology from the University of Wisconsin-Madison, where she researched self-presentation on social media and changing concepts of authenticity. She teaches courses on social inequality in general and gender, sexuality, ability, and race in particular, and serves as chair for 5-2-1, a non-profit advocacy group for bisexual and pansexual people in Wisconsin. She lives in Madison with her husband, two small children, and four cats.

Her hair is pink, her favorite color is rainbow variegated leopard print, and her spectacles are many and varied. You can follow her on Twitter and Tumblr at @cabell, which is the advantage of having a weird name. (It rhymes with “Scrabble.”)


I was in the final trimester of my second pregnancy when I got fat-shamed by a doctor. I’d gained too much weight, she declared, and needed to eat better and exercise.

She never asked me what I ate, and I had literally just finished explaining that, on the rare occasion that I felt like I could handle a single flight of stairs, I was invariably proven wrong—rendered literally immobile by the effort.

The queer erasure started much earlier. At my eight-week sonogram, the ultrasound tech cheerfully scrawled “Hi, Mom & Dad!” across the image she printed out for me. As it happens, there is a dad, but even in supposedly progressive Madison, Wisconsin, it never occurred to the tech to ask. At almost 33 years old, I don’t think I have ever heard a healthcare provider utter the word “bisexual.” The few providers who ask me the gender of my partner hear that he’s a man and assume I’m straight.

Fat and queer people share an often fraught relationship with healthcare providers. The very existence of queer people is often ignored or denied, while fat people find that all other identities are eclipsed by fat, blamed for any and all health problems in lieu of offering actual treatment options. Fat people and queer (especially trans) people often receive grossly inappropriate care, or are denied care all together. Discrimination and outright abuse by healthcare providers are real concerns for queer and fat people, and for many of us, they permeate our entire relationship with medical care.

In addition to physical health problems for which we may receive inadequate or inappropriate treatment, queer women are at an increased risk of mental illness and distress. Women have higher rates than men; queer women higher rates than straight women; bisexual women higher rates than lesbian women; trans women higher rates than cis women.

These outcomes are largely due to what has been termed minority stress. Ongoing or repeated experiences of bias have serious health consequences, both physical and mental. Similarly, it’s very rare that we can show fat to cause a particular health problem (where a correlation exists, it’s more likely to be a symptom, and BMI is a dangerous misuse of statistics), but the way we treat fat people, especially women, absolutely damages their health.

Recent research shows a complex interaction between queerness and fatness, as has been discussed elsewhere. As is frequently the case, while bisexual and lesbian women share some experiences, there are also some important differences.

Bisexual and lesbian high school girls both showed similar rates of extreme weight loss strategies such as fasting for 24+ hours at a stretch or induced vomiting, and those rates were 2-3 times as high as for heterosexual girls. Queer girls attempting to manage stigmatized identities may be more likely to go to extremes to reduce their minority stress load.

Differences emerge, however, when we look at more normative weight loss behaviors. Lesbian girls were less likely than heterosexual girls to engage in these, despite higher rates of “overweight” or “obese” BMI. Bisexual girls, however, were more likely to be attempting weight loss; they were also significantly more likely than heterosexuals or lesbians to see themselves as “overweight” even when their BMI was “normal” or “underweight.”

These less extreme weight loss behaviors should still be cause for concern, and not only because they reveal body image issues. Weight loss behaviors, statistically, are not just ineffective but actively damaging.

In the long term, lost weight is regained with a little extra, a process known as weight cycling. While “overweight” or “category 1 obese” BMI measurements do not correlate with increased mortality, weight cycling does. Dieting is the best predictor of future weight gain, and it has negative long-term health effects such as reduced immune function.

Not all disordered eating behaviors meet clinical standards for eating disorders, but it’s worth noting that eating disorders often co-occur with mood disorders, particularly anxiety disorders like obsessive-compulsive disorder (OCD). High levels of anti-fat bias in society in general and healthcare institutions in particular mean that a high proportion of disordered behaviors related to weight will not be identified as such, especially the more normative “dieting” in which bisexual girls and women are likely to engage. Lack of diagnosis means bisexual women are under-treated for our higher than average rates of mental illness and distress.

Mistaken beliefs that eating disorders are about vanity or a desire to appeal to men may erase the high prevalence of disordered behaviors, particularly extreme behaviors, among lesbian and bisexual women. That bisexual women seem to be more vulnerable to ultimately unhealthy but socially accepted—even expected—diet behaviors than lesbians should be taken primarily not as evidence that we are focused on attracting on men, but that we still lack strong community support, even in settings with a large “queer community.”

That lack of community support has global health implications, for mental and physical illness. As a bisexual woman with PTSD from medical trauma and abuse and OCD (which is exacerbated by stress), I don’t see my bisexuality as central to my disorders per se. But the lack of social support that has at times dramatically worsened these conditions is absolutely connected to my bisexual identity. Like many people, I’d rather just avoid groups where major parts of my identity are unknown, ignored, or denied. If you rarely go out anyway because you’re tired of microaggressions, it takes awhile for people to notice that anxiety and hypervigilance have essentially stopped you leaving your house at all. Without a strong community to lean on, it’s even harder to take the first steps to ask for help.

All too often healthcare providers themselves buy into misinformation and stigma about mental illness, which disproportionately reduces the quality of care received by queer women. At this point in my life, I assess every doctor’s appointment for its likelihood to trigger my PTSD, which doesn’t exactly motivate me to make very many of them. Having a larger body after my second birth just adds another layer to the potential abuse any unknown healthcare provider represents to me.

Because queer women are also more likely to have BMIs categorized as “overweight,” we are then more likely to experience anti-fat bias from healthcare providers in addition to mental illness stigma and general anti-queer bias, affecting both our quality of care and our future willingness to seek necessary care.  Community provides an important buffer; bisexual women need to be valued and respected in both straight and gay communities. Healthcare providers, however, also bear a significant burden here. They need to do better: for queer women, for fat women, for mentally ill women.

FEATURE PHOTO CREDIT: WIKIMEDIA

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12 Comments

  1. Thanks for breaking this down Cabell. I’ve struggled with body image for a long time (started in high school) and this makes me look back and that with more curiosity.

    • I’m glad you found it interesting! As I said, I think people who have one or more stigmatized identities may tend to try to more strictly manage other aspects of their selves/bodies/etc. When you know that at least some people will treat you poorly due to one part of who you are, you may be more willing to go to extremes in an attempt to be “acceptable” in other aspects.

  2. I have started to try and make myself more conscious of the added stress I feel in the doctor’s office or ER because I’m queer. I “look straight” to people who don’t know any better and there is always a coming out moment. And while it is usually not a terrible experience, as we all know, coming out is always an unknown and causes more or less stress, but always some stress.

    It is noteworthy that just today I went to an alternative therapy treatment and the intake form asked for my preferred pronoun. I noticed an immediate relaxation throughout my body when I saw the question. Just because they asked, I knew the place was going to be queer-savvy and queer-friendly.

    In other thoughts, I really liked this piece at Autostraddle on this topic, too:

    http://www.autostraddle.com/lesbian-obesity-study-misses-the-point-we-dont-care-if-were-fat-253569/

    • It definitely helps a lot when providers signal that they are aware of issues that affect their patients, rather than making patients do all the work in a situation where we already have less power than the provider.

      I linked that piece because they’re working from the same study, but they conflated the lesbian and bisexual girls’ results. I think it’s important to recognize the differences between the groups.

    • My massage therapist’s intake form asks preferred pronouns and it’s kind of awesome. I wish more places picked it up!

      (in case anyone’s in Madison WI– http://www.renumadison.com/)

  3. How would our experience of medical care change if a practitioner met each client with the question What is your story? Instead of the assumption that he or she already knows the story. Thanks for raising awareness!

    • I don’t think providers are blameless, but I do think there’s also an issue here where medical care in the US is basically always under a time crunch. Providers who do take the time to listen to patients are under a lot of pressure to spend less time with us, unfortunately.

  4. I’ve been experiencing this a lot lately. Yep, I’m a fat bi girl and instead of being treated according to my symptoms I’m being treated according to my appearance. I have been dealing with severe full body pain and I’ve had two doctors encourage me to lose weight and another brush me off as drug seeking. Woohoo! One of the docs actually semi-listened though and gave me something to try and help with the pain, but he was an ER doc, not my primary, so when those run out I’m up a creek. One of the others told me I need to watch biggest loser and workout till I puke because only that will help me. Oh, and I should just push through my pain and work out even though it hurts and exhausts me to walk to my master bathroom from my bed…

    I look straight and I have kids so unless I mention my wife, people don’t even question that. I’ll admit, I’m happy when that doesn’t come up because I don’t want one more thing against me. None of the providers here are really queer savvy, and none at all are fat savvy.

    The point of this long tirade (sorry!) is to thank you for putting something like this out there. Its reaffirming to know that my thoughts feelings about this topic aren’t totally baseless and that its not just me going through it. Thank you.

  5. This was a really interesting read. It touched on some great issues such as the relationship between dieting, self-esteem, and physical and mental health.

  6. Yes, yes, yes! This is so important, and thank you for posting this well-researched article!

    I am also really fascinated by the differences for bisexual women, both with partners and without. I can honestly say that I hadn’t thought about this in that way.

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