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In the months since the Supreme Court overturned Roe v. Wade, many people have stepped forward to share their stories in order to help destigmatize abortion and join in the fight for reproductive rights. But despite all the important discussions happening in the SCOTUS decision’s wake, there’s one conversation that’s gone vastly unreported: how the overturn of Roe v. Wade is disproportionally impacting people in larger bodies.
“Larger-bodied people are left out of the conversations as if they’re not sexual beings,” says Laura Lindberg, PhD, a researcher in sexual and reproductive health and rights at Rutgers.
The fact is, certain types of contraception — including emergency contraception and birth control pills — might be less effective for people in larger bodies. In a 2014 study monitoring the effectiveness of levonorgestrel (the drug in emergency contraception pills like Plan B), women with a body mass index (BMI) of 25 or higher experienced decreased efficacy; the pill stopped working entirely in obese women with a BMI of 30 or higher. Those findings led to a change in packaging information in Europe, but the US Food and Drug Administration called the data “conflicting and too limited to make a definitive conclusion.” Despite the FDA’s decision not to update labels, doctors who treat “obese” patients told NPR that their patients regularly became pregnant after taking the Plan B pill. Regardless, anecdotal evidence shows many people are still unaware of the drug’s potentially limited efficacy. (As of right now, the only emergency contraception that’s effective regardless of body size is the copper IUD, according to the American College of Obstetricians and Gynecologists.)
“Doctors are taught that one of the worst things their patient can be is fat.”
And if contraceptive methods such as Plan B fail, people in larger bodies face other hurdles: for one, a pregnancy test may not show a positive result as early for someone who’s over a certain weight. Research shows people with a higher BMI are more likely to have lower hCG hormone levels at the beginning of pregnancy, which is the hormone that OTC pregnancy tests detect.
Fatphobia isn’t new in the healthcare industry, but the new abortion restrictions have made its effects on contraception even more problematic. “The truth is, right now, in today’s world, we can’t afford to not educate ourselves about contraception and its efficacy for different bodies,” says Nia Patterson, a mental health advocate who focuses on eating disorder recovery and fat activism. “An unwanted pregnancy that an individual thought they were appropriately protecting themselves from can be the cause of significant financial hardship, physical health issues, or even death.”
Given the recent overturn of Roe v. Wade, access to contraception is more important than ever regardless of body size, but the deeply ingrained fatphobia in our culture is keeping larger-bodied people from being in full control of their reproductive health. POPSUGAR spoke with fat activists and reproductive health equity experts about why this is the case, what needs to change, and how to regain control.
How Fatphobia Shows Up in Healthcare
Put simply, fatphobia is weight bias rooted in a sense of blame and presumed moral failing, according to Boston Medical. It’s often shown in contrast to the ways non-fat, straight-size, smaller people benefit from thin privilege, and can contribute to body shame regardless of a person’s size. “Body shame exists to keep us isolated and bought into pursuing the unobtainable, always-changing appearance ideals,” says Ally Duvall, fat activist and body image program manager at telemedicine company Equip. “We can’t find freedom from body shame without addressing where it comes from and why we are encouraged to dislike our bodies in the first place — it’s the messages we are receiving constantly from diet companies, wellness influencers, and the media as a whole.”
These oppressive systems and beliefs about bodies are inherent and built into every facet of our lives, but the healthcare setting is often where they can have lasting and harmful effects. For example, fatness or obesity are often called out as key contributors to cancer or brain disease, but the reality is that the causes of these illnesses are complex and likely not due to one single factor, especially someone’s size.
As someone with a larger body, Patterson says, “I have faced extensive discrimination due to my body not fitting into ideal medical care standards.” For example, they’ve had weight-loss surgery repeatedly recommended by healthcare providers despite being in recovery from an eating disorder, and they’ve had disability paperwork withheld because they did not comply with weight loss recommendations. “Doctors are taught that one of the worst things their patient can be is fat,” they say.
Why Doesn’t Contraception Work For All Body Sizes?
Studies have shown that certain types of contraception are less effective in women who are ‘”overweight” by BMI standards; however, there’s still much research to be done, as there isn’t an official point at which it’s officially considered “ineffective”. More than one in four American women are considered “overweight,” according to the Centers For Disease Control and Prevention. So, why don’t we have effective contraceptive options for people in larger bodies?
“It’s not lack of access, but a lack of guidance,” Dr. Lindberg explains. There hasn’t been a lot of information up until recently because clinical studies excluded larger bodies, and clinical research is what steers doctors’ recommendations. “You end up with a lot of individual providers using their best readings of very limited literature to counsel their patients,” she says. What we need is to figure out if the contraception is effective for larger-bodied people, “and if so, what are the safety risks?”
A review published in the journal “Reproductive Health” looked at gaps in research and confirmed that there’s a pressing need for qualitative research exploring larger-bodied people’s experiences with routine and emergency contraception, as well as receiving contraceptive counseling and care. “At the very least, medical providers who are providing fat people with these contraceptive devices have an ethical right to inform their patient of the weight efficacy standards,” Patterson says. Meaning, “if they’re going to provide a person with Plan B, they need to tell them that if their weight is above a certain number, then the medication may not be as effective and to allow that patient to make their own decision.”
The Unique Challenges Facing Larger-Bodied People Post-Roe
Beyond less-effective contraception, larger-bodied people face increasing barriers and risks around their reproductive health, Dr. Lindberg says. “Accessing an abortion is already limited by body size. Very high-BMI women have a harder time finding a provider to perform a surgical abortion, so finding a place is even more limited — and if they need to travel out of state, that brings on more cost.” These limitations are primarily related to needing more anesthesia and the size of the equipment available.
“Fatphobia, diet culture, and pretty much all health and beauty standards are first and foremost rooted in a system of control — the control of bodies.
Also, body size often intersects with race — particularly because structural racism contributes to higher BMIs. As a social demographer, Dr. Lindberg focuses on addressing systematic disparities in sexual and reproductive health and rights, which have become increasingly under threat in this legal landscape. “Women of color are more likely to be categorized as larger-bodied, so these policies and practices risk becoming racist,” she says. “Therefore all of these concerns are much more likely to impact women of color.” This includes health risks during pregnancy and higher morbidity rates related to delivery and in the months postpartum.
“Fatphobia, diet culture, and pretty much all health and beauty standards are first and foremost rooted in a system of control — the control of bodies, and on a higher level, oppressive systems like racism, sexism, ableism, and more,” Patterson says. “It is constant and has been going on for centuries.”
How Can You Advocate For Yourself to Get Better Care?
Fat patients are often given subpar healthcare — “at best, leading to misdiagnosis, and at worst, causing their death,” says Patterson. “As someone with a larger body, I often fear doctors will chop my experiences and health concerns down to something as minor as my body weight, even though there’s little to no evidence that my body weight indicates my health.”
Still, people need to see doctors. “Everyone — regardless of their size — need to find a healthcare provider to talk about their specific needs and engage in a shared decision-making process,” Dr. Lindberg says. Start the conversation with your doctor by saying you want to talk about being sexually active. Ask questions like, “If I need emergency contraception, what would I use, and what is the timing on that, given my body size?” Dr. Lindberg says. The more info you have in advance, the easier it will be to access it when the time comes.
Patterson says advocating for yourself might look like bringing a friend or family member to doctor appointments, refusing to be weighed when asked to, and shutting down recommendations of weight loss and weight-loss surgery. They recommend “Don’t Weigh Me” cards — you may have seen them trending on TikTok — which are an easy way to make it clear to your doctor that you’d like to leave your weight out of the conversation, especially as a variable in diagnosis. Ultimately, though, Dr. Lindberg says, “A provider that wants to focus on losing weight might not be the best fit for you. Advocate for yourself in the room and embrace your inherent sexuality.”
Ultimately, Patterson says, “We need to have more conversations around discriminatory stipulations on medical devices and medications and urge the healthcare industry to develop inclusive options.” Because the burden shouldn’t only be on the patients themselves. It’ll take much wider societal change to end fatphobia and ensure all people can get the inclusive healthcare they deserve.