gros.org: stigmatization of obesity

Stigmatization was described by Erwing Goffman as a discrediting process which strikes an individual who is considered as "abnormal" or "deviant". He/she is reduced to this single characteristic in other people’s eyes .
This “label” justifies a range of social discriminations and even exclusion.
Stigmatized individuals then shape themselves based on these rejections by developing a self-devaluation, impairing their body image and legitimizing these negative judgments most often irreversibly.

Erwing Goffman himself had not studied obesity stigmatization. We owe this first definition to W. Cahnman.

By stigmatization, we mean rejection and disgrace associated to what is seen (obesity) as a physical distortion and a behavioral aberration (Cahnman, 1968).

Many authors have studied the social impact of stigmatization by showing how a number of negative behaviors toward obese people can be transformed into real discrimination.
Statistically significant correlations have been shown between obesity and:
- access to higher education (Canning and Mayer, 1966),
- access to employment (Matusewich, 1983, Benson et coll, 1980),
- income level (McClean and Moon, 1980),
- professional advancement (Hinkle et coll, 1968),
- domestic life (Karris, 1977, Myers and Rosen, 1999).

Making judgements starts very early in life. Three-year old children already make stigmatizing judgments. (Cramer and Steinwert, 1998).
Studies made by Jean-Pierre Poulain confirm these results, as well as those made by Jean-François Amadieu on employment discriminations.

These negative behaviors are widespread even among medical practitioners:
Numerous American studies confirm the stigmatization process by medical and paramedical staff in the health institutions (Maddox et coll., 1968 ; Price et coll., 1987 ; Najman and Munro, 1982 ; Myers and Rosen, 1999), and also among medical students (Blumberg and Mellis, 1985).
Numerous accounts of this situation in here in France confirm this trend, although a change seems to have appeared over the last years.
The prevailing epidemiological position labeling obesity as a deviance encourages stigmatization indirectly, but significantly.
The prevention position, although well-intentioned, is massively reinforced by media which serves as a sounding board. Fears of obesity risk factors are constantly brought up, and slimness and thinness images are promoted at the same time. All of this depicts obesity in a strictly negative way.

Individual dimension of stigmatization

Social rejection induces overweight persons to lose confidence in themselves. In some cases, people have been brushed aside early in their life. This has led to major eating and identity disorders.
The professional who is asked to treat people suffering from their weight and from their eating behavior must immediately deal with the individual consequences of stigmatization :

Shame and guilt
In our culture, eating is profoundly linked to guilt.
Being outside of the norms, facing reoccurring failures with diets, losing control due to deprivation, that is to say being in a cognitive restraint state, all this factors contribute to guilt.
According to Serge Tisseron (1992), this guilt is a form of social integration because it takes into account the fact the being overweight is breaking the rules.
Conversely, shame would be a form of non-integration, which creates a break in the person's continuity. His/her body image is affected.

"The individual is rendered completely powerless (he/she has no hold on anything and cannot control anything) which is in fact the mental translation of a collapse. This can affect any part of his narcissistic, sexual or social bonds investments,." (Tisseron. S. La honte. Psychanalyse d'un lien social (Shame. Psychoanalysis of the Social Bonds) Dunod, Paris, 1992, p.3)
This writer distinguishes between guilt, which can be confided in someone in order to be expiated, and shame, which cannot be expiated nor hidden, even from the individual, and is therefore difficult to reach.
He considers guilt as an adaptation of shame as are resignation, ambition, denial, projection and projective identification.
He proposes to deal with shame using the:
- affect (with the various feelings which can be interweaved with it);
- actual perceptions that accompany it;
- images or mnemonic traces in the shamed individual;
- verbal representations he/she can give to him/herself or eventually to others;
- action possibilities induced by shame that incite the person to remove himself from it or conversely to go even deeper into it.

But what exactly is shame ?
Shame appears each time the person is faced with someone who casts a doubt over the idea he/she has from him/herself.
Vincent de Gaulejac (1996) mentions the feelings of illegitimacy, inferiority, public or private decline, and that which is left unsaid which restrains symbolization capacities and inhibition. (from Gaulejac V. Les sources de la honte, (i.e. The Sources of Shame) Descle de Brouwer, Paris, 1996).

For obese persons, shame is internalized. It becomes lasting and embeds itself into the psyche.
Shame can start in childhood or adolescence and consolidates itself, invading the entire psyche. It affects self-confidence and personality reconstruction.
Shame is internalized by stages until it constitutes a "socio-psychic core". We are particularly vulnerable to shame at certain periods of development:
- the mirror stage or narcissism,
- the Oedipus stage or the confrontation with the forbidden and the symbolic order,
- the end of the latency period or the discovery of the social world,
- adolescence and sexual and social choices,
- entrance into adulthood and the pursuit of a place in the society.

These phases are arbitrarily delimited since a continuum exists in one's development, which takes into account internal and external elements.
At each stage, the individual looks for a balance between a more or less grandiose and unattainable ego-ideal, and an ego-representation which is built in a negative manner. He/she is confronted with him/herself and with how others see him/her.
The submission to the look of the others is all the more internalized such that it corresponds to the norm currently in force.

Shame persists where humiliation ends, even, for example, in the case of weight loss.
It can be reactivated during each new situation of rejection and intensifies itself .

Self-esteem is called into question when others underestimate. A specific tension is developed due to self-denial which echoes what is perceived from the judgment of others. The nature of the suffering from this feeling of shame is linked to dignity.

It is at the crossroads of social and psyche.
It is made up of emotions, affects, fantasies, all linked to each other and to : rage, guilt, love, hatred, anger, aggressivity, fear, astonishment, etc. To any one who feels it, it is a particularly painful psychic suffering.
All aspects of one's existence are contaminated, as well as the entire identity in personal and social aspects.
It gives rise to pity or compassion, embarrassment or scorn from other people. Most often, it isolates him/her, since it is difficult to talk about and also to hear.
These phases are arbitrarily delimited since a continuum exists in one's development, which takes into account internal and external elements.
At each stage, the individual looks for a balance between a more or less grandiose and unattainable ego-ideal, and an ego-representation which is built in a negative manner. He/she is confronted with him/herself and with how others see him/her.
The submission to the look of the others is all the more internalized such that it corresponds to the norm currently in force.

Shame persists whereas humiliation has ended, even, for example, in the case of weight loss.
It can be reactivated during each new situation of rejection and potentiates itself .

Self-esteem is called into question when others underestimate. A specific tension is developed due to self-denial which echoes what is perceived from the judgment of others. The nature of the suffering from this feeling of shame is linked to dignity.

It is at the crossroads of social and psyche.
It is made up of emotions, affects, fantasies, linked to each other and to : rage, guilt, love, hatred, anger, aggressivity, fear, astonishment, etc.. To any one who feels it, it is a particularly painful psychic suffering.
All aspects of existence are contaminated, as well as the entire identity in personal and social aspects.
It gives rise to pity or compassion, embarrassment or scorn from other people. Most often, it isolates him/her, since it is difficult to talk about and also to hear.

Psychopathology of exclusion
The psychopathology of this exclusion is not specific. It is the same as all rejection and ostracism situations.
Pierre Mannoni talks about abdication and abdicable behaviors where the individual tends to withdrawal and stay in the background.
Self-esteem is failing. A confused feeling of shame is built upon situations of rejection (being starded at in public, jeers, or insults).
The feeling of guilt about being fat maintains itself and intensifies. It induces humiliating judgments that are often very paralyzing, inflicting real and lasting wounds. Some people struggle to overcome this system of false values whereas others, who go from failure to failure, shut themselves away and develop real social phobia that pushes them outside of any social contact.
This experienced violence can be turned back against oneself with acting-out behavior periods causing or being caused by addiction and eating disorders.
Self depreciation sometimes prevents the construction of social and love relationships.
This can lead to a form of mourning for oneself.

Stigmatization probably does not cause overweight and obesity, but it worsens it and maintains it in a vicious circle that is difficult to overcome and stabilize.
It takes eating behavior out of the social sphere, increases eater anxiety, blurs internal signals of hunger and satiety, and favors compensatory behaviors.
In brief, stigmatization of obesity aggravates eating disorders and leads to weight gain!

Prevention and implicit stigmatization

Faced with the prominent concern about the development of obesity :

Epidemiologists should sound the alarm and look for solutions to curb this phenomenon.

Politicians, in response to the public's general concern, should examine this proprietary public health problem in order to legislate.

MDs who are competent in this matter can only note that univocal solutions don't correspond to the clinical reality. They are divided between following the solutions proposed until now (which haven't resolved anything) and reappraising the systematic medicalization of overweight and obesity.
A minority of physicians questions the validity of the classically proposed solutions and the consequences of their generalization over the entire population. This minority, to which we belong, advocates a bio-psycho-social treatment.

Sociologists who study the consequences of these struggles to fight obesity and the frantic desire for slimness in our society, note unanimously how these can induce a stigmatization of the obese which, as we said, maintains and increases their weight problems.

User associations offer a place for social reconstruction outside of the medical establishment by organizing activities for self-esteem and for the fight against isolation.
Some associations are promoting the acceptance of weight. Indeed, they consider that the cure is worse than the disease, and that one should chose between following the path towards losing weight or towards accepting one's weight and seeking stabilization.
Some other associations provide information for people suffering from their weight problems in order to make them more autonomous, and focus on repairing their self-esteem.
Some others accompany users in their quest for losing weight, focusing sometimes on a specific method.
For a list of association, see: The stout built lobby

As we have seen, the interests and actions of social actors are disparate. under these conditions, how then can we coordinate efforts to propose efficient solutions which won't aggravate the problems?

This is all the more important since prevention itself can be a stigmatization factor. Indeed, this is the case for persons who are not able to lose weight, nor meet the norms and for all those who have gained weight irreversibly during their diet attempts.
The stigmatization problem is then inseparable from preventive measures proposed to fight obesity.

Jeffrey Sobal proposed a model to "face obesity" which is composed of four steps (Sobal 1991):
Recognition. Identify and become aware of stigmatization mechanisms.
Preparedness. Prepare obese people for the effects of stigmatization, enabling them to spot both the various social contexts where it is manifest and the categories of persons who are the real merchants of discrimination ("the great stigmatizers" of Goffman)..
Reaction. Bring together all psychosocial attitudes and behavioral techniques at short and long terms, enabling to better come to terms with stigmatization.
Repairing. Try to make the stigmatization phenomenon known to society as well as to health and administrative authorities and try to promote communication or even legislative reforms which could transform the societal attitudes toward obesity.
These proposals were summarized by the sociologist Jean-Pierre Poulain (Jean-Pierre Poulain, Rossana Proença, Sandrine Jeanneau and Laurence Tibère. "T’as vu comme t’es gros? Faire face à la stigmatization sociale des obèses" (i.e. Have you seen how fat you are? Confronting social stigmatization of obese people , p 11 and 12)

The fight against stigmatization can be considered in two ways :
Assistance and follow up of obese people to help them tolerate and face stigmatization.
Actions with social actors in order to make them aware of stigmatization mechanisms and to limit their effects.

Actions can be taken on different levels:
Communication/advertisement: though public health channels.
School teachers/ especially gym teachers: Physical exercise can be a lever for the integration of obese children and can contribute to their self-esteem rather than their self-devaluation.
Medicine: there is no doubt much to do on this front
Society: we could, for example, try to change the social process that organizes, legitimizes and spreads the representations which underlie stigmatization. Why not organizing massive communication campaigns, support actions to obese defense organizations, or do like what has just been decided in Spain, that being to ban the broadcasting of images of top models who look anorexic and whose BMI is lower than given values?

"A fat person always hopes a little in spite of his all-too-many failures. The other people's eyes ask him to hope. That's heavy look to carry, much heavier than our weight."
Anne Zamberlan (cofounder of Allegro Fortissimo)

Page créée le 18 septembre 2005
Dernière Mise à Jour le 18 septembre 2005.


	The fight against overweight and obesity intensifies. It is mostly focused on questions concerning eating and physical exercise, with no significant success as of yet. It brushes aside those people who don't meet weight norms for staying in good health and having the longest possible life expectancy. Starting at a young age, the fear of becoming fat isolates youngsters who are larger than the admissible body shape, which straightway draws attention to their difference. It is difficult to hide what is visible in a world where slimness is a promoted value and where advertisements keep on reminding us of this and warning us about the risk factors of obesity. Anything that does not meet the norms breaks the rules and becomes a discriminating factor although in a nearly unconscious manner for everybody. We all start keeping a concerned eye on any increase in our weight and we ask ourselves where will the scales finally tip. The fat person becomes the one whom nobody wants to resemble. The consequences of this exclusion are rarely described. And yet, they contribute to increasing difficulties met by some people and participate undoubtedly in the increase of obesity.