Recognizing and Challenging Size Privilege: A Primer for Mental Health Clinicians and Researchers

Abstract

With the prevalence of higher-weight people and the adverse outcomes associated with weight stigma, body size is a necessary component of multicultural training. However, body size has not routinely been included in identity-based prejudice training for mental health professionals. This article aims to support clinicians and researchers in their recognition of, and response to, weight stigma and size privilege. Further, this article asserts that training in sizeism is essential for the multicultural competencies of mental health providers, psychological science researchers, and those in allied fields. As such, methods for recognizing, situating, and challenging size privilege are proposed.

Given the multitude of adverse outcomes of both experiencing weight stigma and internalizing weight-stigmatizing messages (e.g., Puhl & Lessard, 2020), the need to address sizeism and weight stigma within psychology, psychotherapy, and mental health training has been proposed (McHugh, 2019; McHugh & Chrisler, 2019). Despite these adverse health outcomes and weight stigma having one of the highest prevalences of identity-based prejudice (Boswell et al., 2024; Puhl et al., 2008; Puhl & Lessard, 2020), most mental health clinicians and researchers receive no training related to size and weight, even within multicultural and diversity courses (McHugh, 2019). As such, I propose one vital step for nonfat clinicians and researchers in their development as size-inclusive, multiculturally competent professionals—acknowledging size privilege, a socially and culturally constructed privilege. Though this text and subsequent size privilege list is designed within my lens as a psychologist, many allied fields may find this text relevant, along with anyone with size privilege.

Weight stigma refers to negative beliefs about and treatment of those with higher body weight for not conforming to societal expectations of acceptable body weight (Tomiyama et al., 2018). A large body of research has consistently found weight stigma (not weight itself) to be associated with adverse health outcomes, including depression, eating disorders, suicidality, and substance abuse (Carels et al., 2010; Puhl & Lessard, 2020; Simone et al., 2019). Likewise, weight stigma has been reliably found to relate to avoidance of healthcare, reduced exercise, morbidity, and numerous physical health conditions (Prunty et al., 2023; Puhl et al., 2021). Children perceived as “obese” are more likely to be bullied and perform worse on academic markers, and have delays in dating relationships (Puhl & Lessard, 2020). Adult women with higher weight are less likely to be married (which is associated with health and financial outcomes) than thinner women (Sobal & Hanson, 2011). Clearly, the impacts of weight stigma are severe and in numerous domains.

The mental health field is obligated to support the holistic well-being of all our patients and clinical research participants. As such, identifying and understanding weight stigma is needed. However, for professionals who are not fat, another critical step in understanding sizeism is to identify and situate one’s size privilege. Acknowledging thin or size privilege has been recommended by previous scholars (e.g., Bacon et al., 2016; Kwan, 2010) because sizeism is partially maintained through thin privilege and shapes our experiences, whether or not we are aware. For example, given that healthcare providers often exhibit weight stigma toward higher-weight patients (Lawrence et al., 2021), clinicians may be more likely to hold negative attitudes and assumptions toward their fat patients that could impact treatment engagement and outcomes, such as viewing their fat patients as less compliant and capable of behavioral changes. Treatment recommendations and case conceptualizations may also be affected by unidentified size bias. As such, awareness of unearned privilege is an essential step in addressing fatphobia and sizeism within the mental health and allied health fields.

In 1989, scholar Peggy McIntosh published her seminal work on White privilege, which included a list of 26 examples of White privilege. Given the invisibility of privilege and the lack of discussion around size within the mental health field, I borrow from McIntosh and expand upon Bacon and colleagues’ (2016) thin privilege examples. In creating a more extensive list of size privilege examples within different levels (e.g., institutional privilege, interpersonal privilege), my goal is for those with size privilege to better identify and situate their privilege.

Because privilege operates at multiple levels, the size privilege list below is divided into three subsections: institutional privilege, cultural privilege, and interpersonal and personal privilege. Institutional privilege contains items that are enforced at an institutional level and impact access to resources, laws, policies, and infrastructure. Cultural privilege contains items that are due to cultural or societal values, beliefs, norms, and ideas. Interpersonal and personal privilege items are those related to interactions with others or unearned personal perks received due to size.

As a process note, as someone who is not as thin as I once was and who would now identify as straight-sized (not fat, but not thin), I found myself wondering if I am the right person to write about size privilege. As I reflected, though I am no longer particularly thin, I noted these size privileges outlined below continue to apply to me and size is on a continuum versus a dichotomy (fat or not fat). As such, size privileges may also operate on a continuum, and even some smaller fat individuals may have some privileges (e.g., institutional size privilege). I recommend you view this list as simply examples of size privilege and not exhaustive, and the saliency of these examples may also expand or diminish based on the reader’s other identities (e.g., gender, race), roles, and place on the size continuum.

Institutional Privilege:

1. I do not need to worry if I’ll fit in the seats at essential places or services I need (e.g., my doctor’s office, public transportation, friends and family’s homes, restrooms).

2. I know I won’t be asked to purchase two plane tickets or risk being kicked off a flight.

3. I am more likely to get a job, be paid more, and be promoted than a higher-weight individual.

4. I do not need to pay more for health insurance due to my body mass index (BMI), and in some workplaces, I will receive discounts through my health insurance plan for my weight regardless of my actual health behaviors.

5. I am less likely to die prematurely because my doctors ignored my health concerns and instead overfocused on my weight as the primary problem.

6. I can be confident that medications like vaccines and the morning-after pill are calibrated for my weight (e.g., Plan B becomes less effective at 165 pounds).

7. Doctors, insurance companies, or hospitals will not deny me critical surgery due to my BMI (e.g., gender-affirming care, knee surgery, hip replacements).

8. If I need a medical procedure, the gowns, blood pressure cuffs, and medical equipment will all fit my body.

9. I can enjoy many leisure activities without being prohibited by the size of the seating (e.g., restaurants, theaters, roller coasters, massages, chair lifts while skiing, shop for clothing to express myself).

10. I do not belong in a group where public health officials, the government, and the medical system see my weight as an “epidemic” that needs eradicating (e.g., the war on obesity).

Cultural Privilege:

1. My body size is associated with health, beauty, morality, hard work, strong willpower, and self-respect.

2. I can watch television or movies knowing I won’t be the main punch-line or have my entire identity be about food, eating, weight, or body image.

3. I will see people of my size represented widely and positively in the media, and with a range of personality types.

4. I can watch commercials and know my body type will be used as the desired “after” photo rather than the dreaded “before” photo.

5. No shows or movies depict people of my body shape and size as a spectacle (e.g., My 600-Lb. Life, The Whale).

6. I do not need to listen to friends complain about their body size, knowing well that I am what they fear.

7. I know my doctor will not recommend, unprompted, a surgery to me that reroutes my organs and eliminates part of my stomach or medications to lose weight.

8. If my children are thin, I do not have to prepare them with how to handle being bullied for their weight.

9. If I am sexually harassed, sexually assaulted, or raped, people are more likely to believe me.

10. I won’t be discouraged from having children and won’t be perceived as a bad parent simply because of my size.

Interpersonal and Personal Privilege:

1. I know that my weight will not serve as a distraction from my personality, qualities, and traits.

2. I do not have to fear judgment or comments from others about what I am eating or my weight when I am in public (e.g., at a restaurant, grocery store, sitting, working out).

3. I can dress casually, have messy hair, or do something unsavory without being a representative for all people of my size or perceived extra negatively.

4. I do not have to worry that people will assume anything about my hygiene because of my weight

5. I can spend time with family and friends without their preoccupation with my “health.”

6. If I choose, I can enjoy being a “foodie,” eating decadent foods, and eating a lot without hearing judgment from others.

7. I can be sure that people I date will not be interested in me because they fetishize my weight.

8. I can tell a story about how another person was interested in dating me without people voicing surprise.

9. I will be trusted more easily and will not be on trial for my weight when I speak to a powerful group of people.

10. I can write about, teach, and research weight stigma without being accused of being biased. I can worry about weight bias without looking as if I am self-serving. In fact, I can receive more “clout” in these spaces due to my size and weight.

Like all identity politics and acknowledgments of privilege, some nuance and careful reflection are needed. For example, hyperfixation of body size and weight stigma impact us all in negative ways, to varying degrees, even if there are some conferred size privileges. For example, internalized weight stigma can occur among people of any size, even if higher-weight people receive more stigmatizing events (Levinson et al., 2024). Eating disorders occur across the weight spectrum (DSM-5-TR), and people across the weight spectrum with eating disorders have high rates of internalized weight stigma, which is related to symptom severity (Martin-Wagar & Weigold, 2023). Yet, those with higher weight are half as likely as people with average BMI or lower to be referred for treatment (Nagata et al., 2018). Because of fatphobia and weight stigma, people who are not fat may still worry significantly about their weight, experience intense body dissatisfaction, and use harmful weight control behaviors. Some thin folks used to be fat and, as such, may be keenly aware of how they are treated differently based on size. The ways in which thin people suffer are due to our society’s hatred and fear of fatness. Thin people disparaging their bodies hurts fat individuals most. It may be that the negative impacts of weight stigma on people of all sizes delay the recognition of how people who are not fat do have many unearned benefits of their size. This is especially true when thinner people notice individual negative experiences (e.g., poor body image, teasing), yet systemic institutional privileged experiences go unnoticed (e.g., chairs in waiting rooms, wages, and access to healthcare and employment). Like all privilege, thin privilege often operates at a level that is not visible without intentional attention. Acknowledging the ways in which we receive privilege does not take away from individual hardships.

Though sizeism is structural, individuals can perpetuate and maintain structural inequities, often without their knowledge. Identifying size privilege allows us to break through the myth of “earned” thinness and, thus, earned privileges given the sizeable genetic influence on body size and weight (Loos & Yeo, 2022). Realizing our unearned advantages is a necessary step in joining as accomplices in the fat liberation movement. Nash and Warin (2017) and Przybylo and Fahs (2021) note the importance of going beyond identity politics and the stance of “not-fatphobic” (Przybylo & Fahs, 2021, p. 305) to intentionally “anti-fatphobic.” Acknowledging one’s positionality and privileges is not the endpoint, but instead intended to be a beginning where anti-fatphobia work can commence. Personally, I find it helpful to acknowledge and revisit my size privilege because it affirms why I can sometimes have body image concerns (e.g., weight stigma threatens us all, we know we’ll be treated worse if fat), helps me notice where I should speak out, especially with attempting larger-level change (e.g., size-inclusive seating at universities and clinics so people of all sizes can comfortably access these spaces). If I did not intentionally try to recognize my privilege, I might not recognize where others are not so privileged and then I may be less motivated to address sizeism or simply unaware. For example, clinically, I have seen higher-weight patients with eating disorders be delayed in receiving care due to thin individuals having more access to receiving an eating disorder diagnosis due to provider biases. As such, I now educate healthcare providers in my community to screen for eating disorders, regardless of size. For mental health providers and social science researchers, beyond recognizing size privilege or one’s own weight biases, I recommend an intentional focus on how one’s own weight has shaped one’s beliefs and experiences and how higher weight has shaped the lives of fat patients.

Importantly, one’s other intersecting identities may profoundly impact their experience with their size (Smith, 2019). The acceptability of one’s size is contingent on one’s class status, race and ethnicity, gender, sexual orientation, and other identities. Beauty ideals, in general, are profoundly shaped by all systems of oppression. Sociologist Strings (2019) details how fat phobia in the United States originated during the Mid-Atlantic slave trade, before the medicalization of fatness, to encourage thinness among White women as a way to further themselves from Black women and assert racial superiority, and is still used today to further oppress those already marginalized (Strings, 2019). For example, contemporarily, those with higher weight seeking gender-affirming surgeries can be turned away due to their BMI (Brownstone et al., 2021), yet bariatric surgeries are routinely done on people with significantly high BMIs. Women experience weight stigma to a greater degree than men (Puhl et al., 2008). The intersection of socioeconomic status, ethnicity, and weight can create messages that certain ethnic foods are “bad” or “unhealthy.” In contrast, other, often more expensive foods, are denoted as “healthy” and “good.” How one is perceived when eating “bad” foods is deeply shaped by their body size. One’s weight status cannot be entirely separated from other intersecting forms of oppression, and weight stigma furthers other identity-based inequities.

Finally, given the prevalence and impact of sizeism, mental health training programs should include weight status as a multicultural identity within required multicultural competency education. It is uncommon for the mental health field to consider body size and weight as a social identity that confers power and privilege or that is subject to oppression (Bergen & Mollen, 2019; Malone & Ishmail, 2020), and as such, trainees rarely receive formal education on size as a social identity. Van Amsterdam (2013) noted how body size is treated differently from other identities like race and age partially because people believe weight is in a person’s control and changeable. The myth about the controllability of weight may contribute to the lack of inclusion of weight status as a relevant identity within multicultural competence training at most training programs. Though weight is somewhat changeable (with significant effort), it is not changeable for all, nor to degrees that would no longer render many fat folks fat. Often, attempts to change body size require changes that are not sustainable for most (Mann et al., 2007; Wing & Phelan, 2005), and long-term adverse outcomes are not well understood. Alas, other identities included in multicultural training, like age, are subject to, often fruitless, attempts to alter the perception of one’s identity. For example, though one’s age is presently unchangeable, great lengths are taken by some to appear younger through cosmetic surgeries (e.g., botox, fillers), make-up, and clothing. As another example, some who are bisexual may purposely only date someone who helps maintain a heterosexual appearance. Attempts to alter the perception of one’s identity, like the examples above, are often a result of wanting to reduce discrimination and prejudice.

Further, for many, thinness is not something earned but just how one is without effort. Some thin people do not restrict their food intake nor spend much time doing exercise, while some fat people eat quite restrictively and engage in frequent and intense exercise. One’s size is deeply impacted by genetics, socioeconomic status, and access to green spaces and nutrient-dense foods. For other thinner people, thinness may be present due to a depressive episode, cancer treatment, malnutrition, an eating disorder, or other challenging life circumstances. Even if someone has “earned” thinness through personal behaviors, the pathway to thinness may not be through healthy behavior change, and some who were formally higher weight might struggle with how much better they are treated in a small body compared to when they were in a larger body.

Complicating matters further, the relationship between health and weight is complex, with weight science failing to demonstrate a clear and consistent link across health conditions and studies (Flegal et al., 2013). Regarding modifiable risk factors for health outcomes, weight status contributes only around 1.5% to one’s health outcomes, whereas socioeconomic factors are much more saliently related to one’s health outcomes (Hood et al., 2016). When studies find those with higher weight to have lower mortality rates or better health outcomes than those in the “normal” BMI category, the condition is considered part of the so-called “obesity paradox” (Elagizi et al., 2018; Flegal et al., 2007). To date, there are few long-term (over two years) studies of weight management approaches that maintain weight loss for most participants. As such, there is much we do not yet know about the relationship between weight and health, but adverse health outcomes associated with weight stigma are quite clear.

Given the level of weight-based discrimination in society, the link between weight stigma and adverse well-being and health outcomes, intersection with other marginalized identities, and the absence of absolute controllability of one’s weight, weight status should be included as a facet of one’s identity that shapes one’s experience of the world within multicultural competence teachings. Those who train others in the mental health field can expand multicultural training to include size and weight to better address the needs of higher-weight patients, research participants, and others with whom we work (see Bergen and Mollen (2019) for a primer). Recognizing size privilege and understanding how weight status impacts how people navigate the world is but one approach to efforts to incorporate size into multicultural training.

As a final note on size privilege and weight stigma, those with size privilege have not held the burden of having to do the labor to improve the treatment of fat people. It is often fat people themselves who are tasked, often out of necessity, with doing the anti-fatphobia work. Those with power and privilege do not have the same pressure to spend their energy focusing on obliterating size privilege and weight bias because they benefit from and often do not even notice the privilege. Those of us who spend time in fat activist spaces or conduct anti-weight stigma work but have no lived experience with fatness need to be extra mindful that we do not inadvertently harm fat folks. It is everyone’s responsibility to address fatphobia and sizeism. Those without lived experience of fatness should follow the lead of fat activists and scholars in this vital endeavor.