this book is first and foremost an ethnographic account of what it means to undergo extreme weight loss, it is also fundamentally about understanding norms around body, weight, and appearance.9 Norms are shared but unwritten rules about how humans should act and be. Norms help people understand what is expected and what will be accepted by a wider group. What are the processes by which norms infuse themselves into people’s lives? In what ways do these norms form our sense of self and identity, and how do individuals accept and resist them? How do people define success or failure in relation to them? What are the implications when norms change, with regard to the effects on human society and biology?
Our focus in this book is on shared body norms and shared experiences of struggling to meet them. As such, our analysis focuses to a large extent on drawing out core experiences that cut across diverse participants’ experiences over time. In doing this, we focus on similar themes that emerged for people, despite the many differences within our sample with regard to each person’s weight, dieting history, marital and familial situation, socioeconomic status, age, gender, race, and ethnicity. The literature tells us that all of these factors may impact people’s experiences of fat stigma, their sense of self, and their experiences in society. For example, the Centers for Disease Control (CDC) notes that Non-Hispanic Blacks and Hispanics (quoting CDC categories verbatim; we use Black and Latinx in our own descriptions) are at higher risk for obesity and associated chronic diseases than are Non-Hispanic Whites and Non-Hispanic Asians.10 There also is considerable research examining how obesity in the US correlates with lower socioeconomic status and how this in turn creates greater obesity risk among communities that have experienced systematic and systemic marginalization.11 Recognizing this, we address in this book how key socioeconomic differences shape people’s experiences, at least to the extent that is possible given our sample composition.
This study’s sample supports comparisons around gender and, to a much lesser extent, race. The limitations of our race-oriented analysis stem, in large part, from the nature of the clinic itself. It is extremely difficult to gain access for long-term ethnographic studies to clinic settings where patient populations are typically deemed vulnerable. The clinic where we gained permission to do the study was primarily a White space: most providers were White; most patients were White; the bariatric education program was built on medical research reflecting the concerns of mostly White scientists; people in the pictures on the walls of the clinic were mostly White; the anthropologists lurking around the bariatric program were White; and so on. The overall result in this clinic, as in many others, was the production of remarkable cultural uniformity oriented around a (mostly unexplored) set of White norms and interactions.12 One consequence of this, for our analysis, is that telling detailed stories around the experiences of this study’s non-White participants could compromise their confidentiality, making clear to readers who have knowledge of this clinical practice who the specific participants are and what they said. As an experiment to test anonymity and community knowledge, for example, Sarah tried describing one non-White patient to a health-care provider in the clinic, with a few key demographic identifiers—including familial country of origin—changed slightly. The health-care provider immediately identified the patient correctly, thus providing a clear example to us of how insufficient are slight modifications to demographic information for some non-White participants. For us, our ethical obligation to protect participants’ identities and right to privacy far outweighs the inducement to produce highly nuanced theory about race and bariatric surgery in this particular instance.
That does not mean we will ignore race in this book, however, or even intersections of race and gender. One important group of participants, Black women, was numerous enough to produce analyzable data that can be effectively anonymized. Our analytic focus on Black women in a bariatric program provides an especially valuable lens because, as the literature indicates, Black women’s unique intersectional experiences of racism, misogyny, and fat stigma give them keen insights into dominant body norms in the US and the enormous harm the norms can do.13
Socioeconomic status is another important—and often problematic—factor in our analysis. Bariatric surgery itself can be expensive; follow-up surgeries, either for skin removal or to correct a problem, can also be expensive. The Norwegian government offers bariatric surgery to all its citizens whose weight and comorbidities qualify them (a situation that has its own benefits and disadvantages); the United States does not offer the equivalent.14 In the US, therefore, any person interested in bariatric surgery must first figure out a way to cover the substantial associated costs of the surgery before they can proceed. For some, this means paying out of pocket for an expensive surgery with an accredited provider; others are able to get their health insurance to cover the same types of surgery with an accredited provider. Other lower-cost options, however, include going abroad or electing to use an unaccredited program in the US.15
In the accredited program we studied, hospital staff worked hard with all prospective patients to get as much of the surgery covered by health insurance as possible. Over the course of our research, we asked patient-participants how they funded their surgeries and how it related to their economic circumstances. If they did not want to discuss their finances, however, we did not push the point; we were already asking many sensitive questions at a very tumultuous time in people’s lives. What we learned from those who did talk about financial matters in some detail was that the patient-participants lived all over the city and surrounding areas, in neighborhoods that ranged from wealthy to lower income, worked a variety of blue- and white-collar jobs, and expressed varying degrees of worry about covering the substantial expenses associated with their bariatric surgery.
While we acknowledge the—often profound—ways in which gender, socioeconomic status, and race shape experiences around weight, as well as the ways in which we live in and through our bodies, it is also important to show how weight can be an unusually powerful “master status” that effectively swamps people’s many other social identities and achievements.16 Transecting race, class, gender, and place, weight has become a new shared cultural preoccupation, an increasingly universal personal concern, the basis for a billion-dollar weight-loss industry, and a phenomenon that seemingly demands immediate government action. Weight is thus also is a perfect lens for exploring how cultural norms are shared by different people, in different communities.
The dark side of failure to meet norms that are so socially important is stigma. Stigma is a concept that social scientists (ourselves included) have been discussing for a long time in the context of other traits, especially stigmatized infectious diseases like HIV/AIDS. What traits become stigmatized in a particular time and place is socioculturally constructed, meaning that it depends on the views and values of each society. Traits judged as socially unacceptable vary widely across cultures and throughout history. Stigma toward people with fat bodies has a relatively brief history. Understanding what it is to live with fat requires us to directly address the processes that push people who fail to meet body norms downward and even out of society.
Stigma, as a judgmental response to nonconformity with social norms, is also understandable as a broader political tool for keeping people in line and penalizing them if they stray.17 For example, Americans who pride themselves on their tolerance and open-mindedness toward diversity in other aspects will often display high levels of unexamined fat stigma. Fat stigma remains widely acceptable and accepted across many sectors of society; unlike other prejudices that characterize modern American life, it also cuts across social classes, ethnic groups, and geographic areas. We ourselves encounter it on a regular basis within academia, when we describe what we study. “Why would you worry about what a bunch of fat women have to say?” was one such comment from a colleague.
The power that is implicit in such negative judgment about who and what has value also speaks to the power that sociocultural norms possess for shaping both health and the health system. We concentrate in this book on norms around weight, fat, and body, paying particular attention to the ways the acutely aware bariatric participants articulate and react to these norms, both through interviews and more generally during our participant observation in their clinic. We also consider the implications for people’s longer-term engagement with weight-related issues once they leave the clinic, because
