CENTERING THE MOST MARGINALIZED

Categories of Fat Access

Medical

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Note: The term “bariatric” is used within this section in conjunction with equipment designated as such. The term “inaccessible” can mean that the equipment literally cannot be accessed or that it can only be accessed with pain or discomfort. Accessible diagnostic and imaging equipment is often the most expensive, in effect levying a “fat tax” on the most marginalized fat people.

Ironically, medical facilities where they have weight-loss surgery programs are often best equipped to care for the heaviest patients. They typically have bariatric tables and wheelchairs, hovermats, and transfer devices with high weight capacities. In addition, anesthesiologists and surgeons who routinely operate on very fat people may have skills and techniques that their peers do not.

CATEGORY LABELS

We refer to various categories of fat access based on the experience of how a person is impacted by anti-fat bias. Not all people are impacted by anti-fat bias equally. Fatter individuals experience more anti-fat bias and to represent this increase in experience we’re looking to find new category names to represent the levels of anti-fat bias different individuals receive.

LEVEL DEFINITION
Level 1 Inaccessibility
Level 2 Restricted Access
Level 3 Limited Access
Level 4 Basic Access
Level 5 Systemic Access

CT SCANNERS

Some diagnostic imaging tables have a weight limit of 350 pounds.

LEVEL DEFINITION
1, 2 CT scanners are inaccessible
3, 4 Some CT scanners are accessible
5 Most or all CT scanners are accessible

X-RAY RADIOLOGY

LEVEL DEFINITION
1 X-ray radiology is inaccessible
2, 3, 4 X-ray radiology is sometimes accessible
5 X-ray radiology is almost always accessible

Diagnostic Imaging

CLOSED BORE MRI

Most closed bore MRIs have a diameter of 24” and a circumference of 74”. It’s important to note that the table sits within the MRI, so part of the diameter space is below the table.

LEVEL DEFINITION
1, 2, 3 Closed-bore MRIs are inaccessible
4 Some closed-bore MRIs are accessible
5 Most or all closed-bore MRIs are accessible

OPEN BORE MRI

Most open bore MRIs have a diameter of 27.5” and a circumference of 86”. It’s important to note that the table sits within the MRI, so part of the diameter space is below the table.

LEVEL DEFINITION
1, 2 Open bore MRIs are inaccessible
3, 4 Some open bore MRIs are accessible
5 Most or all open bore MRIs are accessible

OPEN MRI

An open MRI has a working space 36” wide and 18” tall. Open MRIs may have a weight limit of 550 pounds.

LEVEL DEFINITION
1, 2 Open MRIs are inaccessible
3 Some open MRIs are accessible
4, 5 Most or all open MRIs are accessible

Medical Equipment

EXAM TABLES

Standard tables typically have weight capacities of 400 pounds, while bariatric exam tables are often rated up to 800 pounds. Other factors that impact exam table accessibility are the height and width of the table, whether it is bolted to the ground, whether it has wheels and, if so, whether the wheels are locked.

LEVEL DEFINITION
1, 2
 Exam tables are inaccessible
3, 4
 Some exam tables are accessible
5 Most or all exam tables are accessible

SCALES

A weight measurement is sometimes needed for medication or anesthesia dosage. Factors that impact scale accessibility are weight limits, availability of a stable item to hold while stepping onto the scale, width of the base, and width of the space between grab bars. Wheelchair accessible and standing scales with weight limits of 800 pounds or more are manufactured. In addition, bariatric beds can typically read weight. However, the availability of this equipment is location-specific.

LEVEL DEFINITION
1, 2
 Scales are inaccessible
3
 Some scales are accessible
4, 5 Most or all scales are accessible

SURGICAL TABLES

Bariatric tables with weight capacities up to 1,000 pounds are manufactured.

LEVEL DEFINITION
1, 2
 Surgical table weight capacity is too low
3, 4
 Most surgical tables have an adequate weight capacity
5
 Virtually all surgical table weight capacities work

WHEELCHAIRS

A standard wheelchair is 26” wide by 26” deep. A bariatric wheelchair is 35”-39” wide.

LEVEL DEFINITION
1
 Wheelchairs are inaccessible
2, 3, 4
 Some wheelchairs are accessible
5 Most or all wheelchairs are accessible

BLOOD PRESSURE EQUIPMENT

The American Heart Association recommends the following cuff sizes for various adult arm circumferences. It does not have a recommendation for arms larger than 52 cm/20.47”.

Adult arm circumference Recommended cuff size
45 to 52 cm (17.71 to 20.47 in) 16 × 42 cm (6.29 x 16.54 in)
35 to 44 cm (13.78 to 17.32 in) 16 × 36 cm (6.29 x 14.17 in)
27 to 34 cm (10.62 to 13.39 in) 16 × 30 cm (6.29 x 11.81 in)
22 to 26 cm (8.66 to 10.24 in) 12 × 22 cm (4.72 x 10.24 in)

Blood pressure equipment is not designed for cone-shaped arms, and an inadequate blood pressure cuff results in false high readings. Manual readings are typically more accurate than machine readings. Provider bias can also influence accuracy of blood pressure readings and actual blood pressure.

LEVEL DEFINITION
1, 2, 3
 Blood pressure unlikely to be read accurately
4, 5
 Blood pressure almost always or always read accurately

AMBULANCE STRETCHERS

The weight limits of stretchers range from 350 to 800 pounds. It’s crucial that first responders are notified in advance of the patient’s weight.

Medications

Clinical trials most often exclude fatter people, yet fat people may be prescribed those medications. For example, Planned Parenthood advises that emergency contraception with levonorgestrel (e.g., Plan B) may not work for those who weigh more than 165 pounds, and that emergency contraception may not work at all for people who weigh 195 pounds or more.

LEVEL DEFINITION
1, 2, 3
 Medications have not been tested for dosage and efficacy
4
 Some medications have been tested for dosage and efficacy
5
 Medications have been tested for dosage and efficacy

Healthcare Providers & Facilities

Healthcare providers are typically not trained in treating fat people, and typically bring anti-fat bias into the healthcare setting. As a result, fat patients are often denied treatment, provided with inadequate treatment, or treatment is withheld contingent upon weight loss. Gender affirming care, organ transplants and joint replacements are commonly denied because of BMI. The lack of evidence for denial is apparent in the wide-ranging limits among facilities. For example, one facility may refuse an organ transplant for a patient with a BMI over 35, while another may refuse patients with BMIs over 40. Ironically, while studying fat bodies has the potential to counter both anti-fat bias and increasing knowledge, most teaching hospitals refuse donor bodies with a BMI of 35 or higher.

MEDICAL FACILITY ACCESSIBILITY

Fat people often avoid healthcare due to anti-fat bias. One of the ways anti-fat bias shows up is with inaccessible waiting areas and exam rooms. Accessibility varies greatly from location to location. Facilities that are more accessible have chairs without arms, chairs with varying heights, and wider chairs. Yet these still may be inaccessible to the fattest patients.

MEDICAL SCHOOLS

LEVEL DEFINITION
1, 2, 3
 Schools do not train physicians and advanced practice professionals to treat patients
4, 5
 Schools do train physicians and advanced practice professionals to treat patients

Medical Treatment

LEVEL DEFINITION
1, 2, 3, 4
 Fat is used as an excuse to withhold treatment
5
 Fat is not used as an excuse to withhold treatment
LEVEL DEFINITION
1, 2, 3, 4
 Denied procedures based on BMI
5
 Not denied procedures based on BMI
LEVEL DEFINITION
1, 2, 3, 4
 Denied necessary surgery until intentional weight loss (IWL)
5
 Not denied surgery until IWL
LEVEL DEFINITION
1, 2, 3
 Denied necessary surgery but offered weight loss surgery (WLS)
4, 5
 Not denied necessary surgery and not offered WLS

Navigating the medical system from someone who experiences Inaccessibility

“Navigating the medical system has been a time consuming, frustrating, discouraging, and occasionally terrifying battle for me, as a 1 on this scale. The challenges vary in severity, from fairly minor things like discomfort and bruised thighs from waiting room chairs that were just not built to accommodate larger bodies, to something as serious and life-threatening as winding up in the ICU due to a misdiagnosis based upon biased assumptions about my body. I now manage chronic illnesses and doctor visits have become a frequent reality for me. Nearly every doctor appointment requires a large amount of mental and emotional labor spent advocating for myself, by declining to be weighed, demanding proper fitting blood pressure cuffs, and pushing back when they consistently try to “prescribe” weight loss as a treatment plan, among many other things. Finding a doctor who will listen, finding facilities that can accommodate me, and advocating with physicians, nurses, and insurance companies to ensure I am receiving the treatment I need are all essential and exhausting parts of confronting the medical industry as a person to whom it is inaccessible and it can often feel like you are fighting just to be seen as a human being.”

Navigating the medical system from someone who experiences Systemic Access

“When I need to address a medical challenge, I just grab any insurance related cards that may be needed and go to the doctor. My doctor and I discuss what the symptoms have been and the doctor gives an earnest attempt to give me some diagnosis of what the problem is, and what treatment will fix the situation. My weight is never mentioned as a problem that needs fixing. I am charged money in exchange for potential solutions to the problem and then move on with life.”

Outpatient surgery Narrative from someone who experiences Inaccessibility

“Going to a hospital for surgery can present extra challenges for a person who experiences Inaccessibility. Before even arriving, I often feel anxiety that the waiting room might have limited or no seating that can accommodate my size. After being brought to the surgery prep room, the staff is oftentimes unprepared for anyone needing a hospital gown and socks larger than a size XL. Many times, I have encountered lengthy waits while the nursing staff gets a larger size gown or socks sent from another part of the hospital. While subjective, I have often found the “bariatric” gowns to be less visually appealing than the standard sizes, with harsher colors like rust orange and mustard yellow instead of the light blues and greens, and white used in smaller sizes. Some hospital staff, nurses, and doctors have made assumptions about my mobility rather than asking me or simply observing my abilities. Sometimes, they don’t have a scale with a high enough weight capacity and I have an additional wait while one is delivered. After being properly attired and weighed, someone comes to put in an IV line, which is something I dread, as only about 1 in 5 nurses are skilled in finding a good vein in fat arms. I am often poked several times in various places on both arms until they find a good spot and I end up with lots of bruises where they were unsuccessful. Next, I meet with the anesthesiologist. This step is extremely important – I have to be bold and ask if they are experienced enough and comfortable putting someone of my size under anesthesia and intubation. If they seem unsure or show any anti-fat bias, I will not proceed with the surgery. I have firsthand experience with how crucial this is, after having an inexperienced and fatphobic anesthesiologist who intubated me incorrectly, causing my heart to stop and I nearly died during the procedure. In that case, the hospital subsequently tried to blame me for being too fat, alleging that it was my fault the intubation didn’t work because of the size of my neck. As a result, I now try to meet with and evaluate the anesthesiologist well ahead of the day of my surgery, and will not proceed with a surgery if I have not had a chance to speak with the anesthesiologist beforehand. I always do a vibe check now, and I have to trust my gut. If I have any doubts, I will stop and reschedule. I cannot put my life at risk again. After the chat with the anesthesiologist, I am taken by gurney to the surgical room. I have had some trouble with them not being able to transfer me from the gurney to the operating table. Usually hovermatt air transfer will work, but sometimes, I have had to awkwardly crawl or roll myself onto the table from the gurney. After surgery, I wake up in the recovery room and after an assessment to ensure I am doing well, they will bring me back to the initial prep room to change back into my clothing and leave. Since hospitals will usually require you to have a family member or friend accompany you to drive you home, I always try to make sure the person I bring with me is a fat ally and recommend others do the same.”

Long-term hospital stay from someone who experiences Inaccessibility

Content warning: Due to the nature of anti-fat bias in the medical industrial complex, the term “bariatric” is used repeatedly in this narrative because that was the easiest way for me to ask for things that met my needs within a hospital setting

“Being stuck in the hospital as someone who experiences Inaccessibility can be a difficult time. Often, the beds are uncomfortable for anyone and especially so as someone in a larger body. I am over the weight capacity of many standard hospital beds, which makes it difficult or even impossible to adjust the bed into a sitting position or otherwise. The beds are not quite wide enough either, and I am often afraid I might fall out the side where the railing isn’t up. The hospital staff has advised me that they can’t put the railings up on both sides for safety reasons. If the hospital does have a bariatric hospital bed, they are usually a type of air mattress that inflates and deflates in a rotating pattern continually to shift the amount of pressure on different parts of your body to allegedly help prevent bed sores. However, these do not work well for a recurring injury I have in my left buttock. If the injury is bad enough for me to be in the hospital, it is best if I can be very still, rather than having my body be consistently shifted. When I could not walk due to injury or illness and I needed to be moved from my bed to a gurney for scans or tests, they typically needed to use a hovermatt air transfer or this crane-like device that picks you up like a stork picking up a baby. These usually work, but sometimes can malfunction. I have had the hovermatts fail and create an embarrassing situation when I got stuck halfway to a gurney and they had to gather a small group of people to try to move me. At times when I have been unable to walk due to an injury or recovery from said injury, I have needed to use a bedpan and have found that most are too small or the nurses and aides don’t know how to correctly place them for my body size. I would frequently overflow the bed pan or partially miss the pan due to the bad positioning. When this happened, I would then need to be washed and have my gown changed as well as the sheets, almost every time I needed to pee. It can be embarrassing and upsetting. It made me hesitant to drink water to try to limit how frequently I had to go, but being dehydrated is not also not ideal when you are recovering from an illness or injury. Some of the aides and nurses seemed grossed out by my fat body. This makes sponge baths or showering with help on a bariatric shower chair awkward and uncomfortable. Some nurses and doctors have been critical of my food choices when I was merely picking from the couple of limited options given to me by meal services. There are of course nurses and aides that are great and non-judgemental, but unfortunately this is not always the case. I have found that hospital doctors listen to me the least of all doctors. I think this can partially be attributed to their busy workload, but it is often clear that it is in combination with anti-fat bias. The lack of listening has led to errors like ordering MRIs or CT scans for the wrong part of my body. These delays have kept me stuck in the hospital for longer and can become expensive if they try to charge me for the incorrect scans that I didn’t need. I find self-advocacy is essential, and I often have to repeat myself. As with many medical scenarios, I find it can help if you have a friend or family member who is a fat ally to help you advocate for your needs and get out of the hospital sooner.”