Stigmatisation and shame – a qualitative study of living with obesity
The study describes how people with obesity experience stigmatisation and shame. Adults with a body mass index (BMI) of more than 25 are considered to be overweight, and those with a BMI over 30 are classed as obese (1). In 2016, 13 per cent of the world’s adult population has obesity. According to a Norwegian public health report from 2017, approximately 1 in 4 middle-aged men and 1 in 5 women have obesity (2).
Malterud and Ulriksen define stigma as an intersubjective phenomenon that is constructed via interaction with an individual’s immediate surroundings (3). Weight stigma is defined as ‘the social rejection and devaluation that accrues to those who do not comply with prevailing social norms of adequate body weight and shape’ (4). Weight-based stigmas can lead to social devaluation and discrimination and can manifest themselves in most interpersonal relationships (5).
According to Luoma, shame is the emotional core of the experience of stigmatisation (6). Shame is a self-related and self-evaluating emotion that is connected to a form of self-awareness in which one no longer owns one’s own body (7). In self-stigmatisation, the socially devalued status of an overweight person is internalised (8).
The World Health Organization claims that obesity is one of the most pressing health challenges today (1). Throughout the world, there is a cultural understanding of obesity as a moral failure that leads to impaired health and quality of life. Brewis et al. argue that the way in which shame and discrimination are linked to obesity will gradually undermine public health efforts (9).
The norm in Western societies is to be slim, and those who suffer from obesity are constantly confronted with this ideal (10–13). Society’s rhetoric in the description of obesity is itself stigmatising, with wording such as ‘an obesity epidemic’, ‘the fight against obesity’ and ‘the war on the obesity epidemic’ (14, 15). People with obesity are regarded as a medical, financial and social liability in society (14, 15).
At an individual level, people with obesity are often portrayed as less physically attractive, undisciplined and greedy individuals who should be ashamed of themselves. Someone who is overweight is often regarded as lazy and having a weak character (3, 15). An additional burden also exists in the form of a moral imperative on the individual to treat and take preventive action against obesity (15).
People with obesity find that society’s body norms are also reflected in the gaze of professional helpers. This reinforces the stigma and shame (16). They feel they are excluded for being abnormal, and avoid contact with the health service (12, 14, 17).
It is not possible for people with obesity to escape the cultural message. Thus, the experience of being overweight can overshadow their entire life and become ‘the very scene of life’ (3). Anyone who does not have the ideal body can perceive stigmatisation as a signal that he or she does not quite fit in, which can make them feel that they are not a fully-fledged human being (16, 18).
Kahan and Puhl (5) claim that weight-based stigmatisation and shame are underreported as a health challenge. The subject of weight stigma is largely absent both at the individual level of treatment and in the national discourse, as well as in health-promoting measures and political priority areas (19). The first step in facilitating health-promoting measures for this vulnerable group is to learn more about their experiences of weight stigma and the associated repercussions on health (19).
Objective of the study
The study explores how people with obesity experience stigmatisation and shame. Knowledge can help improve the health service’s approach to this group, and increase society’s understanding. The objective of the study is to gain a deeper understanding of how people living with obesity experience stigmatisation and shame.
The study is based on a phenomenological-hermeneutical epistemology perspective and has an exploratory design. Qualitative research interviews were conducted, which helped to provide insight into the individual’s lifeworld (20). The hermeneutic aspect of the project represents an interpretive approach (21).
Gadamer claims that the interpretation of meaning is the human way of being in the world, and the study explores the deeper meaning. New understandings can arise when we are open to the unknown and are willing to challenge our own preconceptions (22). The author is a nurse with an interest in health-promoting processes, which influences her preconceptions.
Participants and data collection
The study is based on qualitative in-depth interviews conducted on 18 people who suffer from obesity. The participants represent a convenience sample and were recruited at the start of a three-week lifestyle change course at a Norwegian rehabilitation institution. The course leader at the clinic provided written information about the research project to all participants. Of the 30 people who were invited to participate in the study, 18 agreed. They informed the staff at the clinic, who forwarded their telephone numbers to the author.
The participants were contacted, and the time and place of the interview were agreed. Fifteen women and three men participated in the project. The information letter explained informed consent and gave details concerning anonymity. The inclusion criteria were a BMI over 30, age 18–75 years and an interest in expressing themselves orally. The research project was assessed and approved by the Regional Committees for Medical and Health Research Ethics (REC number 2015/1720).
The author conducted the interviews, which lasted between 30 and 90 minutes. An open approach was adopted in the interviews: ‘Describe what living with obesity is like for you. How do you view yourself?’
In order to prepare participants for the fact that the interview would touch on sensitive issues and emotions, the information letter described how bodies and weight gain can be difficult to talk about as doing so may make some people feel vulnerable.
The transcribed interviews were analysed using Kvale and Brinkmann’s qualitative analysis method with three levels of interpretation (20). Each interview was reviewed in its entirety to gain an overall understanding of what it was about. The first step in the analysis and level of interpretation was to identify the individual’s self-understanding. Meaning-bearing units in the dataset were extracted and arranged under provisional category titles that closely resembled the quotes.
The second step of the analysis and level of interpretation was to provide a reasonable, general interpretation of what the participants said. Using careful abstraction, the participants’ self-understanding was reformulated, and new themes were created, which are presented in the findings. The themes were generated as part of a hermeneutic process whose validity was verified as the parts and the whole fell into place (22).
The findings illustrate obese people’s experiences of stigmatisation by culture, society and immediate surroundings, and how the stigma is an integral part of them that brings with it a sense of shame. In the third level of interpretation, the empirical data leads us to relevant theory that can deepen and broaden the understanding of the data. The theoretical understanding and further interpretation of the data are explained in the discussion section.
The analysis of the transcribed material shows that the interviewees’ comments describe three perspectives on how stigmatisation and shame are created and sustained:
- Pressure from society
- Offensive behaviour in immediate surroundings
Stigmatisation and shame are expressed directly in the material and are also interpreted from the descriptions.
Pressure from society
People with obesity feel pressure and a sense of shame as a result of society’s focus on body image. This group is particularly exposed and susceptible to enormous pressure, as the size of a person’s body is always visible. The message from society cannot be ignored and robs them of the freedom to be themselves and have their own thoughts about themselves:
‘What is it that makes me reproach myself? It has a lot to do with society. There is a focus on exercise and dieting that is totally insane. There is the sense that society nowadays has a very narrow mindset.’
This cultural pressure manifests itself in various ways: ‘Am I less successful and less gifted, not wise enough to realise that I should lose weight?’
The health service conveys a similar message in its approach to people with obesity: ‘It only makes me feel more guilty when I’m told that I shouldn’t eat this and that. Being taught about what it is to be overweight is stupidity. Those of us who are overweight know perfectly well what is wrong. We can see our extra kilos. I believe that both the health service and the majority of the population believe that this is self-inflicted.’
People with obesity feel that there is no place for them in the public domain. They do not feel welcome: ‘Try buying sportswear when you weigh 137 kilos. When you go to the gym, the training equipment specifies a maximum body weight!’
They have a fear of being redundant: ‘I’m afraid of being pushed out of my job, not counting, not being given training or responsibilities. I want to show that I count. I think about that a lot.’
Offensive behaviour in immediate surroundings
Most of the interviewees feel that they are being continuously monitored by the people around them. Other people’s feelings towards people with obesity are reflected in how they look at and talk to this group – through verbal and non-verbal communication. These experiences leave their mark on people with obesity and add to the shame they deal with in everyday life:
‘If I go to a cafe, they’re watching every bite you take. It’s a bit like “being fat is stupid because taking that piece of cake is stupid.” If I had been them, I would no doubt have thought: “Oh my God, she’s so fat! Why is she taking that piece of cake, can’t she just leave it?” You recognise the look. They can’t hide their condescending attitude.’
Although the impressions from the outside world can be strong, people are starting to rally against the idea of being defined by society. Action is needed to reduce the vulnerability of those who are living with obesity. Dealing with it through self-ridicule reinforces their vulnerability: ‘I've always laughed it off, but I feel fake and weird afterwards. So I’ve now started saying that I don’t appreciate it, and then it gets very quiet, embarrassing and silly.’
Another says the following: ‘I joke about myself, joking about it to them, but am sad inside.’
Obese people feel that they need to answer for their body and the extra kilos: ‘That’s good that you’ve lost weight. You need to keep it off now.’
They find it annoying when people praise them for losing weight. ‘It’s as if they’re saying: “You’re on your way to becoming a fully-fledged human being now”.’
Others are reminded of their weight on a daily basis: ‘Yes, there’s a few extra kilos there since the last time I saw you; yes, you’re doing well; how fat you’ve gotten.’
People living with obesity are also shaped by their own self-understanding, which creates a certain disdain for themselves and their bodies:
‘Thinking about what they think just makes me depressed. I view myself as horribly fat and bulky, someone who has failed, with a weakness. But I’ve had a job, and I haven’t failed at all. My first evaluation of anyone is: ‘Are you fat, or are you thin? Do you work out?ʼ So I think that others are also focussed on that. It affects my self-esteem.’
Participants express in different ways that they are a burden to themselves and others: ‘When I went out with my friends, I was thinking: “It must ruin their chances of getting a man when they’re with me, being the way I am”.’
Obese people’s bodies and appearance are continuously being judged. Feeling less attractive creates a self-fulfilling prophecy and makes them withdraw: ‘When I’m fat, I feel less attractive. I probably don’t behave like I’m attractive either. I do after all tend to keep myself to myself! I haven’t managed to maintain my social life. Everything depends on my weight. If I’m invited to a club and I feel that I’m the wrong weight, I won’t go.’
Their own foundation is a breeding ground for shame: ‘I feel a kind of hopelessness. Shame and hopelessness are connected here and are a big part of my personality. But how am I going to change it? I could give up. Why should I struggle with this? Can’t I have a good life instead, for the rest of my life, being as ugly as I am, and now soon to depart this world.’
The shame is exacerbated by hiding what they eat: ‘I think that I’ll only have one slice, but I plan to eat more when the others have gone to bed. It’s associated with shame, it’s bad. When I comfort eat, I get a feeling of self-loathing.’
Shame and pride fight for space: ‘The dream is to feel that you are completely normal in appearance, someone who blends in, and no one reacts, no one thinks: “Oh God, look at that belly or those thighs or that backside or those arms, look at her eating, oh dear!” I want to be completely normal. Yes, thinner and more elegant! So that I can hold my head up a bit and feel a bit of pride in my appearance as well. I do feel some pride in who I am on the inside.’
The objective of the study was to explore the correlations between stigmatisation and shame, and their impact on people who are living with obesity. On the basis of the findings, I will discuss the possibilities for preventing and managing stigma and shame at the individual level and at the societal level.
A key feature of the findings is that the devaluing voice from society and the immediate surroundings is dominant and can lead to internalised stigma. The internalisation is reflected in the way that the participants talk about themselves: overweight people are stupid, less gifted, unsuccessful, failures. Obesity is a deviation from the normative body, and people who experience self-stigma view themselves as having a devalued social identity (6, 15).
The study also shows that the impact of weight stigma and shame on the participants’ health is a challenge that they described using words such as hopelessness, sadness, resignation, not being counted, being a burden on their immediate surroundings and withdrawal and isolation. Studies confirm that self-stigma leads to a sense of worthlessness and isolation, with loss of self-actualisation (3, 6, 23).
In the phenomenology of the body (24), an individual with obesity is an exposed object for the other (7). The pre-reflective embodiment as a form of innocence and immediate being-in-the-world can be lost, and the person loses their spontaneity. Pre-reflective embodiment refers to the relationship we have with our body, which we do not normally give any thought to, but with which it is possible to have a conscious relationship. Shame leads to a person losing sight of the future (7, 23).
Having to act in accordance with culture
People with obesity cannot escape the cultural context, but must find a way to cope with the influence of culture (3). Their efforts to move forward so that life can be lived is expressed in the findings as an endeavour in self-understanding: ‘I want to count, I have begun to speak up, I want to be completely normal and be proud of my appearance.’ But they also exhibit a resigned attitude: ‘How am I supposed to change this?’
There is a longing to have the normalised body, whilst simultaneously expressing a sense of hopelessness and powerlessness. Welz claims that individuals cannot shed the sense of shame on their own; it has to be done in a dialogue with others (25). Fuchs argues that it is crucial to maintain a metaperspective: ‘Taking a metaperspective on situations that cause shame and guilt helps to cope with the self-devaluation [...]. The capability of adopting a metaperspective depends on an open interpersonal space which allows for freedom of self-distance.’ (7, p. 234, 240).
The informants in the study describe hurtful shame, but there are also traces of pride associated with their inner qualities. It is essential to highlight these elements of pride as building blocks to entering a freer space with themselves, their bodies and their lives. Using the Danish philosopher Kierkegaard’s writings about love, Lippitt illustrates how healthy self-love represents a kind of pride (26).
Shame can paralyse us and prevent us from living a full life, while self-love can help us liberate ourselves from shame. By doing so, we open ourselves up to future possibilities (26).
Extensive weight discrimination
Weight discrimination is a global health challenge and is found in recruitment, educational institutions, the mass media and the health service. Social measures are needed to address this widespread health threat (9). A broader effort is required in society to combat weight stigma than has been the case so far, according to Puhl and Suh (19).
Malterud and Ulriksen argue that, as part of the qualitative care for people with obesity, health policy and the field of medicine must acknowledge the body weight prejudices that exist in our culture. In doing so, they will enable those affected to mobilise their own health resources (3). Future obesity prevention initiatives and treatments must give greater empowerment to people living with obesity instead of reinforcing stigma, shame and guilt (19).
Implications for clinical practice
Healthcare personnel are well positioned to contribute to health-promoting change processes, both at the individual level and at the societal level (4). The health challenges associated with stigma and shame and the consequences of these challenges cannot be solved without preventative efforts in a societal perspective.
Medvedyuk claims that the focus of health research and the health service makes victims of obese people. It is therefore essential that healthcare personnel set aside these cultural and negative norms and treat such patients with openness and without prejudice (27). Changing the focus of society and treatment services from weight reduction to greater efforts to address how people are affected by obesity can help reduce stigmatisation (5).
Weaknesses of the study
The study’s findings help us understand some of the correlations between and consequences of stigma and shame, but cannot be generalised as they stand. Vulnerability in connection with stigma and shame is experienced by everyone differently. The sense of shame is concealed within the stigma and is expressed both explicitly and implicitly in the interviews (6). The validity of the study is enhanced by the rich data provided in the interviewees’ descriptions (20). Earlier research also emphasises correlations and consequences, which further validates the findings.
Internalised stigma can crystallise into shame processes, thereby limiting quality of life. The ability to overcome shame as a result of self-stigma lies in developing a resistance to shame, something that can only be achieved in a dialogue with others.
As healthcare professionals, we play an important role in supporting those who suffer from obesity and in enabling them to view themselves as fully-fledged human beings. We also have a responsibility to highlight this aspect of obesity in the public domain and thus help society as a whole to be accepting of obese people.
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