Sunday, August 12, 2018

The Turkey Awards: Obesity Eugenics via Fertility Treatment Denial


We've been talking about Obesity Eugenics, when authorities try to keep people of size from reproducing through negative media campaigns, scare tactics, risk hyperbole, apocryphal stories, push for normal BMI before conception, and pressure for sterilization or termination. This incredibly insensitive and discriminatory movement is the winner of not one, but two Turkey Awards. It's time to call out these egregious practices.

If you aren't familiar with them, the Turkey Awards are the "prizes" I hand out to highlight fat-phobic treatment of people of size from care providers, biased attitudes or studies from researchers, or troubling trends in the care of fat pregnant women these days.

Last year's Turkey Award was delayed so I'm doing two years in a row now. I've already done the first half; attention to the Obesity Eugenics Media Campaign. Now it's time to highlight the egregious lack of access to fertility treatment for people of size.

In past years, we've talked about:
We've already seen in the previous Turkey Award that many care providers believe that "obese" women have no business being pregnant. As a result, there has been a concerted public health campaign in recent years to reduce pregnancies in high BMI women. Today we talk about one of the most widely accepted and insidious ways the medical establishment promotes Obesity Eugenics ─ by denying access to fertility treatment.

Lack of Access to Fertility Treatment

Headline from The Hamilton Spectator, 2011
Denying access to fertility treatment via BMI restrictions is a widely-accepted practice in the medical community. It is driven by risk hyperbole, economics, and weight bias.
“Fat women only have babies because we can’t stop them; we’re certainly not going to help you conceive.” – Family Practice doctor to woman dealing with infertility
In many fertility clinics these days, women above a certain BMI are not permitted to access fertility treatments. In many clinics the cutoff is a BMI of 35, but in the U.K., the limit is usually a BMI of 30. Here is one story of a woman denied fertility treatment and pressured for bariatric surgery because of her weight.
The first thing out of the gynaecologist's mouth was “How much do you weigh”. 135kg [297 lbs]. “Do you realise how obese you are?” I then told her I have been working hard to lose weight through diet and exercise, thinking to cut her off before she got into her fat-bashing rant. As I explained that I had lost 15kg since January, was doing 90 minutes of cardio at the gym 5 times a week, and eating a low GI, low-fat, low-carb diet. She rolled her eyes at me in disbelief. Her reply was, “You are too fat for a baby. You need to get down to 65kg [143 lbs.] before I will help you”. At that point I should have stood up, told her to go f*** herself and walked out but I was stunned. I guess she took the stunned silence as agreement because then she whipped out the lapbanding pamphlet and told me I had to have weight loss surgery. 
Stories abound of women denied fertility treatment because of weight. One woman was told by her Reproductive Endocrinologist (RE):
Pregnancy is supposed to be beautiful and natural and it can be neither at your weight. I suggest you lose 100 pounds then come back.
Here is a story from the comments section of the defunct blog, My OB Said What?!?:
I...had an amazing RE last time, but she has since retired and the only one in town will not treat me due to my weight. He will not do any infertility treatment on you unless you have a BMI under 30!! Really? Because last time I got pregnant with injections and IUI [Intrauterine Insemination] I was 330!!! I had an amazing pregnancy and a healthy baby! Why is okay that...because I have a medical issue and disease I do not deserve to have children. UGH! I can’t even start on how this way of thinking pisses me off!!
Another woman in the same story wrote in the comments section:
We have a good ob/gyn...but we cannot find a reproductive endocrinologist who will even agree to see us.
BMI limits on fertility treatment is one of the most accepted ways doctors try to keep obese women from reproducing. It's another step on the path towards Obesity Eugenics.

The PCOS Conundrum



It's true that heavier women have higher rates of fertility problems. However, it's important to note that just because you are larger, it doesn't mean you will have trouble having a baby. Lots of plus-size women have babies without help. That includes me; I was told I would probably not conceive without fertility help, but conceived four children naturally with no problems. So don't just assume (or let your doctors tell you) that if you are fat you probably won't be able to have kids.

But it's important to acknowledge that some high BMI women do have more difficulty conceiving a pregnancy. Doctors often blame higher levels of estrogen, but the bottom line is that many fertility issues in women of size can be traced back to PolyCystic Ovarian Syndrome (PCOS), which leads to higher levels of estrogen.

In PCOS, women have a hormonal imbalance, probably because of underlying insulin resistance due to impaired insulin signaling. They have too much estrogen and testosterone, but not enough progesterone. As a result, the body ovulates sporadically, weakly, or sometimes only rarely. Ovarian follicles containing eggs either don't finish ovulating or ovulate only weakly. The ovarian cysts that are a byproduct of this process give off excess hormones, and can cause distressing symptoms like excess facial and body hair, thinning scalp hair, cystic acne, body tags, darkened skin around the back of the neck, armpits, etc. It also leads to reduced fertility.

In PCOS, the woman often experiences erratic menstrual cycles, which make it difficult to become pregnant. She may not ovulate regularly, or if she does, she may ovulate only weakly. If she does manage to conceive, she may have difficulty sustaining the pregnancy because of low levels of progesterone to support the the early weeks of pregnancy. In other words, the problem may be conceiving a pregnancy, or a high miscarriage rate afterwards, or both. While there are some women with PCOS who have the ovulatory phenotype and do not have problems conceiving (I'm one of these), many women with PCOS have fertility issues.

PCOS is one of the most common cause of fertility issues. Australian research suggests that up to 72% of women with PCOS have fertility issues, and PCOS often leads to long-term weight gain due to insulin resistance. While many people with PCOS are heavy, not all are, but the fertility effects of PCOS are independent of BMI. Thin women with PCOS experience fertility problems too, but they are able to access fertility help more easily than their heavier sisters.

There is an erroneous belief among some doctors that being fat or gaining weight can cause PCOS. This is an unproven assumption based on fatphobia and allows doctors to blame women with PCOS for their condition. It is far more likely to be the opposite ─ PCOS is most likely an inherited underlying metabolic condition that then triggers weight gain. One review states:
Familial aggregation of PCOS strongly supports a genetic susceptibility to this disorder.
Weight gain does tend to make PCOS symptoms worse, but it is likely the underlying condition that causes weight gain in the first place. Although it is not impossible to lose weight with PCOS, it is much harder. And not everyone who loses weight with PCOS finds that it helps their symptoms. Many people spend years yo-yo dieting because it is so difficult to lose weight with PCOS.

It is a cruel irony to then deny heavy women with PCOS access to fertility treatment. It is a double blow because they are the very ones who need help the most. It's simply a genetic condition that is inherited through no fault of their own, but they are being punished for that genetic inheritance.

Treatment Success Rates

Headline from The Globe and Mail, 2011
Many infertility doctors justify denying fertility treatment to obese people because they contend it is less likely to succeed at high BMIs, and the risk for complications if pregnancy occurs is too high. Let's take a look at these arguments and see if they hold up.

To be fair, there is considerable research that suggests lower rates of Assisted Reproductive Technology (ART) ) success in heavier women and a higher rate of miscarriage after fertility treatment, although not all studies agree. These results seem to confirm that health issues like PCOS play a strong role in infertility in obese women. But it doesn't mean that these women should be penalized for their genetic vulnerabilities.

It's probably true that a higher BMI has a generally lower success rate of fertility treatment to regulate menstrual cycles and help ovulation occur, but that doesn't always translate to actual live birth rates. When looking at live birth rates, some research has found very similar rates of ART success in obese women. One recent Israeli study found similar pregnancy and live-birth rates between all BMI groups and concluded:
The results of our relatively large retrospective study did not demonstrate a significant impact of BMI on the ART cycle outcome. Therefore, BMI should not be a basis for IVF [In Vitro Fertilization] treatment denial.
When funds are limited, doctors argue that fertility treatment should be limited to those most likely to achieve a pregnancy. However, even when funds are available or people pay for their own treatment, many fertility doctors withhold treatment for people of size. It's not just about saving money.

Most tellingly, doctors do not deny fertility treatments to other groups (like older women) who may have lower success rates. Only obese people are penalized like this. 

This is a form of selective discrimination. If older women have access to fertility treatment, so should high BMI people.

What About Weight Loss Before Fertility Treatment?

Image from The Unnecessarean
One of the arguments for BMI limits in fertility treatment is that losing weight first improves outcomes. The British NHS Guidelines state that "most overweight women would only need to lose 5 to 10 per cent of their body weight before they would be able to conceive without needing treatment." The advantage of this is that it could save lots of money and increase success rates. However, the evidence is not so clear.

Some research does suggest higher rates of ovulation in obese women with PCOS who lose weight before fertility treatment. This is why many doctors require that high BMI people lose weight before treatment is permitted. They figure a low-cost intervention like this is worth trying before resorting to high-cost ones. That is a logical argument.

However, while weight loss may improve ovulation and pregnancy rates, does it really result in more babies? What is most important is the final outcome, i.e. live-birth rates. And not all studies agree that weight loss improves actual live-birth rates. 2017 review found:
The existing data from randomized trials...have failed to document improved live-birth rates after the [weight loss] intervention compared with control groups.
A study in infertility clinics across several Nordic countries found statistically similar live birth rates among obese women (BMI 30-35) who were subjected to a very-low-calorie liquid diet for 3 months before In Vitro Fertilization (IVF). Another study found that an intensive weight loss intervention before IVF actually resulted in decreased IVF success.

An important 2016 study in the New England Journal of Medicine found that live birth rates were actually slightly better in the non-weight loss group that proceeded directly to fertility treatment than in the group subjected to a 6 month "lifestyle intervention" program (i.e. weight loss) before treatment:
...The primary outcome [live births] occurred in 27.1% of the women in the intervention [weight loss] group and 35.2% of those in the control group..In obese infertile women, a lifestyle intervention preceding infertility treatment, as compared with prompt infertility treatment, did not result in higher rates of a vaginal birth of a healthy singleton at term within 24 months after randomization.
A follow-up of this study found that the lifestyle intervention in anovulatory women resulted in more spontaneous conceptions but made no difference in live birth rates.

The benefits of weight loss before fertility treatment are mixed. While some people of size do find increased success with spontaneous conception with a modest weight loss, other people of size do not. To blithely suggest that a 5-10% weight loss is all it takes to conceive is insensitive and unrealistic. It may help some; for others it may be a waste of valuable time. Weight loss can be offered to larger women if they are interested since it helps some achieve pregnancy, but the choice must be left up to them, not mandated.

Furthermore, time is a complicating issue. If women put off pregnancy to pursue weight loss, they are losing some of their most fertile years. It can take a long time to lose weight down to required BMI cutoffs. As one critic noted:
Restricting fertility treatment on the grounds of BMI would cause stigmatization and lead to inequity...Time lost and poor success of conventional weight loss strategies would jeopardize the chances of conception for many women.
Surveys suggest that very few women in their 30s are willing to delay seeking fertility treatment in order to pursue weight loss. They know that advancing age is a far more important risk factor than weight.

Others are unwilling to pursue weight loss because even a small loss often results in long-term weight gain rebound and they are unwilling to risk that, especially in pregnancy. A high drop-out rate in weight-loss-for-fertility programs is an additional problem, suggesting that many of these programs are not sustainable or practical.

As a result, there are some doctors who suggest an emphasis on good nutrition and exercise a few months before treatment is more effective than a weight loss emphasis.:
Lifestyle modifications, in particular a healthy diet and exercise during the 3-6 months before conception and during treatment, should result in better outcomes than requiring weight loss before fertility treatments.
This is compatible with a Health At Every Size® approach. Focus on lifestyle and habits, not the scale. Healthy habits are very important before pregnancy but they doesn't necessarily result in weight loss.

Perceived Risks of Obese Pregnancies

Headline from The National Post, 2016
Many fertility docs justify denying treatment to high BMI women because of the perceived risks of pregnancy at larger sizes. They are concerned that the risks of an Assisted Reproduction Technology pregnancy will magnify the risks of a high BMI pregnancy, creating an extremely unhealthy outcome. However, research shows that the two risks are generally not synergistic.

Some doctors believe that fat women are at SUCH high risk that they can't possibly have a healthy pregnancy or a healthy baby. While that's simply not true, it is a strongly held belief of many fertility doctors. Toronto fertility specialist Dr. Carl Laskin says:
“To me, it’s a medical issue. It is not a discrimination issue. [Obese] women are running risks in pregnancy, and if they’re running risks in pregnancy, why should you be helping them get pregnant?” Dr. Laskin has a BMI cut off of 35. “Mine is a brick wall,” he said. "Other clinics will go as high as 40. Some have no cut off."
Bill Ledger, a professor of Reproductive Medicine at Sheffield University in the U.K., reflects the extremism of some doctors' beliefs:
Doctors shouldn't be helping women have a pregnancy that's at a high risk of going horribly wrong. 
Many reproductive endocrinologists (REs) feel that "it would be unethical to help a fat woman get pregnant."  From a comment left on my blog in a past post:
I just went to a gynecologist this past week ...I was told, quite directly, that she would not and nor would any doctor in my HMO take me on since my BMI would make the pregnancy too high risk to myself and a fetus.
An article from 2016 has the doctor throwing down the Fat Death Card (if you get pregnant you'll probably die so we mustn't help you):
One woman recounted a fertility doctor telling her, “Gals your size, OK, mortality rates are higher. So I go ahead and intervene, help you get pregnant here. Then you go down to (a birthing ward). And then, boom! Pulmonary embolism.”
Again, this goes back to risk hyperbole. People of size are more at risk for blood clots, some of which can go to the lung (pulmonary embolism), and that is potentially lethal. But the actual incidence of such incidents is quite low. Furthermore the risk can be lowered with good care by using blood thinners when indicated, not doing cesareans unless truly needed, keeping women as mobile as possible all throughout pregnancy and afterwards, and increasing postpartum surveillance for blood clots in women at increased risk.

Furthermore, the argument about risk is a spurious argument because it is not applied equally. 

Doctors justify denying fertility treatment because women of size do have a higher rate of pregnancy and birth complications, but they weaken their argument by not applying it equitably:
...the objection is that it excludes a specific patient category on grounds that are not applied to treatment of others with comparable risks.
In other words, there are many other groups (like older women, people with certain medical conditions) that have similar or higher risks for complications but these groups are NOT denied access to fertility treatment. Only fatness is penalized in such an across-the-board way. As one review put it:
...a higher risk than the mean IVF population does not mean that it is irresponsible to take that risk. It is a question of proportionality: a higher risk can still be acceptable in light of the gain a woman can expect from treatment. Through the same reasoning IVF is thought acceptable in other women who are at increased risk of pregnancy complications because of medical conditions. Women with diabetes mellitus have an increased risk of hypertensive disorders and congenital abnormalities, macrosomia, stillbirth and premature labour...Diabetes mellitus is, however, not an exclusion criterion for fertility treatment.
Another recent review agreed:
Given that patients with, for example, diabetes or previous pre-eclampsia, who are at higher risks than many obese women, are allowed treatment on the basis of individualized and well-informed decision-making, we think there is no justification for taking a different line with regard to BMI.
Although fertility doctors like to pretend that denial of treatment is based on their concern for risks, they don't apply these rules equally among groups. The same standards are not applied to other women at higher risk for complications; only the obese are targeted. 

Research also shows that while some risks are increased in people of size, the increase in risk is moderate, and many women of size actually have perfectly healthy pregnancies and births. Furthermore, group statistics cannot predict any one person's outcome. Denying fertility treatment based only on weight limits or BMI means that many pregnancies that would have had normal and healthy outcomes will never occur.

Some experts refute the idea that BMI should be used as a surrogate for unacceptable risk levels:
Dr. Cheung plans to argue that studies also show IVF does not pose unacceptable risks for heavy women, and that BMI alone is not a good measure of which patients face the highest risks. Age, he said, is "by far the strongest indicator" of success and dangers.
An article highlighting the Canadian debate agrees:
But to Dr. Yoni Freedhoff, a specialist in weight control at the Ottawa Bariatric Medical Institute, that’s part of an “insidious” health care practice. 
“It would seem to me that this ‘you’re too fat to have IVF’ policy probably is in part started as patient safety, but ultimately it reflects weight bias,” he said. 
Freedhoff, who’s advised assisted reproduction patients needing to lose weight, doesn’t dispute that excess pounds can cause additional risks. What he doesn’t understand is why weight might exclude women from fertility treatment, but other factors that have been shown to adversely affect pregnancy — such as smoking or advanced age — are not perceived as equally damaging.
Ethics and Eugenics Questions

Headline from The Independent, 2018
Infuriatingly, in some areas, helping an obese woman with fertility is seen as malpractice and authorities forbid or strongly discourage allowing fertility docs to treat women of size. According to guidelines in the UK:
Fertility clinics should defer treating obese women until they have lost weight through dieting, exercise or surgery, according to guidelines published today. Under the recommendations, clinics are advised to begin treatment on severely overweight women only once they have reduced their body mass index (BMI) to below 35. Women under 37 years of age should reduce their weight further, to a BMI of less than 30, the guidelines state.
Here's a story from a woman in Australia:
I’ve been to two fertility specialists and neither of them will give us any fertility treatment until I have a BMI of under 35 (99kg). Nothing to do with my chances of getting pregnant; they say it’s an ethical matter, that obesity itself is enough of a health challenge for the body without adding the impact of pregnancy. Getting an obese woman pregnant would be seen as doing harm. The second OBGYN informed me it’s a state-wide guideline according to the Fertility Council which covers public & private health.
Although there are fertility docs out there who believe that it's wrong to deny fertility treatment to fat women, BMI restrictions are common in many fertility practices and some government healthcare.

In New Zealand, Australia, and Canada, there are guidelines in place/ being proposed to prevent women over a BMI of 35 from accessing fertility treatment. In the U.K., women under the age of 37 must have a BMI of no more than 30. In the U.S., guidelines are more individualized, but many clinics have policies in place that bar fertility treatment above a certain BMI, usually 35.

And now things are going even further. Some areas of the U.K. are proposing limiting fertility treatments to women whose male partners have a BMI over 30. The woman can have a "normal" BMI which would ordinarily get her IVF, but if her partner is fat, she doesn't qualify anymore. So not only can they deny treatment to fat women, but to fat men and any woman with a fat male partner.

Some fertility experts  recognize the major ethical problems with denying heavier people access to fertility treatment. An article about proposed BMI limitations on fertility treatment in Canada notes:
...It's ethically troubling," said the University of Manitoba's Arthur Schafer, director of the Centre for Professional and Applied Ethics. "In our society, the decision to procreate is left to the individual – so why would it be appropriate for the doctors to usurp those rights for women who are obese." 
Doctors would only be justified, he says, if they could "honestly, hand-on-heart say," that the safety risks are so great "that no reasonable fat woman would want to conceive a baby in this way." 
"I'm not sure the fertility industry or association can really defend a blanket exclusion on obese women having access to assisted reproduction."
Intersectional stigma applies here too. Another article from Australia notes that the impact of these policies is often discriminatory towards various racial groups and poorer people:
"They need to recognise that there's harm in doing nothing. Women who are unable to have children, there's a much higher risk of depression and anxiety and a doubling in the suicide rate. So doing nothing is not necessarily doing the best thing." 
The guidelines, he claims, can be classified as discrimination."Especially when you consider the low socio-economic group," he said. 
"The Indigenous patients have a lot higher incidents of obesity than the general population, so you're almost discriminating against those two disadvantaged groups in this particular policy. "Obviously that wasn't the original intent, but that is a potential end product of that."
Here is what one group of experts argues in response to the usual excuses for denying fertility treatment based on BMI (my emphasis):
Obesity is associated with a reduction in fertility treatment success and increased risks to mother and child. Therefore guidelines of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) suggest that a body mass index exceeding 35 kg/m2 should be an absolute contraindication to assisted fertility treatment such as in vitro fertilisation IVF. 
In this paper we challenge the ethical and scientific basis for such a ban. Livebirth rates for severely obese women are reduced by up to 30%, but this result is still far better than that observed for many older women who are allowed access to IVF. This prohibition is particularly unjust when IVF is the only treatment capable of producing a pregnancy, such as bilateral tubal blockage or severe male factor infertility. 
Furthermore, the absolute magnitude of risks to mother or child is relatively small, and while a woman has a right to be educated about these risks, she alone should be allowed to make a decision on proceeding with treatment. We do not prohibit adults from engaging in dangerous sports, nor do we force parents to vaccinate their children, despite the risks. Similarly, we should not prohibit obese women from becoming parents because of increased risk to themselves or their child. 
Finally, prohibiting obese women's access to IVF to prevent potential harms such as 'fetal programing' is questionable, especially when compared to that child never being born at all. As such, we believe the RANZCOG ban on severely obese women's access to assisted reproductive treatment is unwarranted and should be revised.
Amen to that. Now if only the health authorities would listen. Unfortunately, they seem to be going in the opposite direction, getting more stringent in their weight-related restrictions, as seen in the U.K. limits on male partners too.

Summary


Headline from abc.news.au, 2017
A few brave medical professionals are speaking out about the discrimination happening in fertility treatment despite tremendous pressure from their colleagues. There have been a number of articles published recently in OB journals questioning the ethics of BMI restrictions but so far, none of the national guidelines have changed. And as noted in the U.K., things seem to have gotten even worse.

Bottom line, denying fat people access to fertility treatment is another form of keeping fat people from having children, but many doctors resist acknowledging the implications of these restrictions. They tell themselves they are protecting their patients with these guidelines. They tell themselves it's all about the risks, yet other groups with similar risks are not penalized. They refuse to acknowledge that they are infantilizing larger-bodied people and taking away their personal autonomy over crucial life decisions.

Authorities think that they are doing fat women a favor by insisting they lose weight before pregnancy, yet by insisting on such weight loss they deny women timely intervention when fertility treatments are most likely to succeed. The number of people who lose weight to a "normal" BMI and keep it off is quite small. When authorities insist on a much lower BMI as a requirement for treatment, they basically are keeping fat people from having children. Intentional or not, this is Eugenics.

Denial of treatment is based on weight bias, the assumption that all fat people voluntarily brought on their weight through poor health habits, sloth, and gluttony, and would perpetuate those bad habits to the next generation. Doctors assume that fatness is easily solved through altering health habits and exercising a little more willpower, but this argument does not hold up under scrutiny.

Research is very clear that most people are unable to lose weight and keep it off long-term, so denying treatment until someone reaches an "ideal BMI" or even a 5-10% reduction is unrealistic and delays fertility treatment until it may be too late. As some experts note;
Age trumps everything, so if your plan is going to make these women lose weight, the time that might take them if they’re older is going to be way more significant than any potential benefit in terms of weight loss.
Weight loss surgery does reduce BMI, but research shows significant trade-offs. There are reduced risks for gestational diabetes and large babies, but also increased risks of prematuritytoo-small babies, and possibly neonatal mortality. There are no easy answers here.

Potential health complications is a red herring argument. The underlying reason weight has been made an automatic disqualifier is because doctors see people of size as unfit parents who will create more fat people. Sure, there are some fat people who do have poor health habits but so do many thinner women, yet they are not kept from fertility treatment. If health habits were the main concern then EVERY patient should be screened for this and used as a barrier to treatment for all sizes, yet it's only targeted to obese people.

Furthermore, many fat people have medical causes for their weight such as Polycystic Ovarian Syndrome, lipedema, hypothyroidism, etc., and these conditions can impact fertility as well. To deny people with conditions like PCOS treatment is to penalize them for their genetics. People should not be punished for their genetic vulnerabilities.

People of size should be informed of the potential risks of pregnancy at larger sizes, but in a realistic way, not through scare tactics. People of ALL sizes should be encouraged to practice healthy habits and have great nutrition, and should be counseled about their individual risks. In most cases, though, the decision on whether to proceed with fertility treatment must be the person's. The government or a group of doctors has no business controlling whether or not a person has children. It infantilizes women and takes away personal autonomy to impose such rigid guidelines.

Denying fertility treatment based on weight basically keeps a whole group of people from having children and that's always a suspicious restriction that smacks of eugenics.

Those who would deny fertility treatment based on BMI are trying to be the gatekeepers of who are "allowed" to reproduce; this is another insidious form of eugenics and must STOP.


Resources

If you are experiencing fertility issues, here is a brief set of links to resources that might be helpful:
References

*The full list of references for this post are far too long to include. Instead, here are a few key references and quotes. The other references are scattered throughout the article and have links to the original sources and studies. 

Studies Critical of BMI Limits on Fertility Treatment

Should obese women's access to assisted fertility be limited? A scientific and ethical analysis. Tremellen et al. 2017 Aust N Z J Obstet Gynaecol https://www.ncbi.nlm.nih.gov/pubmed/28299785
Quote: "The absolute magnitude of the risks to mother or child is relatively small, and while a woman has a right to be educated about these risks, she alone should be allowed to make a decision on proceeding with treatment...we should not prohibit obese women from becoming parents because of the increased risk to themselves or their child...."
Should access to fertility treatment be determined by female body mass index? Pandey et al., 2010 Human Reproduction.  www.pubmed.gov/20129994
Quote: "Restricting fertility treatment on the grounds of BMI would cause stigmatization and lead to inequity...Time lost and poor success of conventional weight loss strategies would jeopardize the chances of conception for many women."
It is not justified to reject fertility treatment based on body mass index. Koning et al., 2017. Human Reproduction Open. https://academic.oup.com/hropen/article/2017/2/hox009/4049574
Quote: "Given that patients with, for example, diabetes or previous pre-eclampsia, who are at higher risks than many obese women, are allowed treatment on the basis of individualized and well-informed decision-making, we think there is no justification for taking a different line with regard to BMI."
Should overweight or obese women be denied access to ART?: Comment by: Ahmed Badawy, Middle East Fertility Society Journal, 2013. https://www.sciencedirect.com/science/article/pii/S1110569013001106
Quote: "Those who are choosing to postpone childbearing for the weight reduction should balance the negative effects of aging versus obesity on fertility and perinatal outcomes... there is no strong evidence for the association between obesity and live birth in infertile women. Thus, there is insufficient proof to refute women fertility treatment on grounds of BMI."
We need to stop discriminating against plus-size pregnant women. Raina Delisle, Today's Parent, 2017.  https://www.todaysparent.com/pregnancy/pregnancy-health/we-need-to-stop-discriminating-against-plus-size-pregnant-women/

Women with obese male partners will be denied IVF treatment, rules NHS group. Tom Embury-Dennis. Independent, 2018. https://www.independent.co.uk/news/health/women-obese-men-denied-ivf-treatment-bmi-30-bath-north-east-somerset-ccg-a8248061.html

Should high BMI be a reason for IVF treatment denial? Friedler et al., 2017 Gynecological Endocrinology  https://www.ncbi.nlm.nih.gov/pubmed/28531369 
Quote: "The results of our relatively large retrospective study did not demonstrate a significant impact of BMI on the ART cycle outcome. Therefore, BMI should not be a basis for IVF treatment denial."
Randomized Trial of a Lifestyle Program in Obese Infertile Women. Mutsaerts et al., 2016 New England Journal of Medicine https://www.ncbi.nlm.nih.gov/pubmed/27192672
...The primary outcome [live birth rate] occurred in 27.1% of the women in the intervention [weight loss] group and 35.2% of those in the control group (rate ratio in the intervention group, 0.77; 95% confidence interval, 0.60 to 0.99). CONCLUSIONS: In obese infertile women, a lifestyle intervention preceding infertility treatment, as compared with prompt infertility treatment, did not result in higher rates of a vaginal birth of a healthy singleton at term within 24 months after randomization.
Mr. Fertility Authority, Tear Down That Weight Wall! Hum Reproduction 2016 Dec;31(12):2662-2664. Epub 2016 Oct 19. Legro RS1. PMID: 27798043  Full text here
Discussion of the 2016 NEJM study above and subsequent subanalysis. Quote: "The impression from these epidemiologic studies and the smaller interventional trials is that obese women are damned if they do lose weight prior to pregnancy and damned if they don't. As the LIFEstyle study indicates, dropout rates with lifestyle modification are high (20%), the average amount of weight lost is modest (4.4 kg) and most women will not achieve the targeted weight loss (62%). Furthermore, women who participate, regardless of age, initial BMI and ovulatory status, will experience cumulative lower rates of a healthy baby... pending further studies, these cumulative data suggest that weight limits used to deny women access to fertility care are not only arbitrary, but discriminatory, and clearly not evidence-based.
  

Tuesday, July 31, 2018

9th Turkey Awards: Obesity Eugenics Media Campaigns


A fairly recent article in an Australian newspaper ─ October 2016 ─ had the inflammatory headline, "Call to stop obese women from having babies." The picture below it featured a woman with a slight double chin and said, "Experts warn obese women should not have children."

Well, here we go again with the Obesity Eugenics Wars. This incredibly discriminatory movement is the winner of not one but two Turkey Awards. It's time to call these egregious practices out.

If you aren't familiar with them, the Turkey Awards are the "prizes" I hand out to highlight fat-phobic treatment of people of size from care providers, biased attitudes or studies from researchers, or troubling trends in the care of fat pregnant women these days.

In past years of the Turkey Awards, we've talked about:
I haven't done a Turkey Award in quite a while, so I'm doing two years in a row now. To make it easier to read, I'm splitting one giant post up into two. Today's post is about attention to the Obesity Eugenics Media Campaign and its impact on women. In the future, we will highlight the egregious lack of access to fertility treatment for high BMI women and how this plays into Obesity Eugenics.

Obesity Eugenics: The Media Campaign

Headline from 2016 Australian news article

There has been a concerted public health campaign in recent years to vilify fat pregnant women, scare them away from pregnancy via risk hyperbole, and present only negative stories about fat pregnancy in the media.

This is because many doctors seem to believe that fat people have no business having children. Here's a recent comment from one OB:
Obese women shouldn't even get pregnant. 
This is a common opinion among some healthcare providers. While having a miscarriage, one women of size was scolded for being upset. She was told:
Why are you crying? It’s not like you lost anything. A woman your size has no business being pregnant anyway.
The caption under the picture for the above news headline is
Experts warn obese women should not have children. 
Although these experts justify their actions by saying it's for the sake of the children to get around criticism, that's baloney. This is nothing more than weight bias, pure and simple, combined with the arrogant belief that doctors should be the gatekeepers to who is allowed to reproduce. 

And that is completely unacceptable.

Objective Reporting?

Article from the New York Times, 2015
There have been a series of media articles in recent years designed to discourage obese women from having children unless they reach a "normal" BMI first. These articles have hardly been objective. They use scary headlines, cite worst-case scenarios, use emotionally manipulative language, and rarely represent any other point of view.

Because of our society's dogged belief that obesity is all about willful sloth and gluttony, communication about pregnancy in people of size has taken on an ominous moral overtone. The implication is that if the mother would only show a little self control, she could stop irresponsibly putting her baby at risk. Some imply that obesity during pregnancy is equivalent to child abuse.

Some articles portray fat mothers as despicable food addicts, akin to drug addicts and alcoholics, endangering their babies with their addiction. In the U.K., National Health Services health chief Jonathan Sher recommended in 2016 that certain women should be advised not to have children:
He wrote that “health professionals, pharmacists and community workers” should all take part in giving the advice to these groups of women, who include the obese, drug addicts, domestic violence victims, and women who suffer from depression.
Lovely. So now fat people are looked at the same as drug addicts? A 2015 article trumpets that it's time to "make obesity the new pregnancy taboo."

Well, we are certainly well on our way towards doing that. Look at the titles of a number of recent articles or books about obesity and pregnancy.
These are not the titles of objective pieces. These articles don't just raise awareness about risks. These articles have an obvious overt agenda, and that is to strongly discourage fat women from having children at all.

These articles are not meant to inform, but rather to scare, shame, and intimidate women of size. They're meant to promote a climate of hostility towards high BMI women among healthcare providers and society in general. It's meant to paint people of size as irresponsible and out of control. It's fat-shaming and scare-mongering, pure and simple.

Often, these articles feature an apocryphal story of an obese woman with severe complications as a cautionary tale. This is often a woman of color, accelerating the stigma even further. These stories imply that fat women are all at equal risk for such a dire outcome, and that anyone who dares to be Pregnant While Fat is the ultimate Bad Mother. Or as one blogger puts it, "fat is the new crack" in bad-mother blaming.

Anyone reading these articles might well conclude that virtually no fat woman has EVER had a healthy pregnancy or a healthy baby, that the ONLY way to have a healthy pregnancy is to lose vast quantities of weight first, and that the vast majority of fat women experience MAJOR complications and bear only deformed or doomed babies. And that simply doesn't jibe with the experiences of most fat mothers.

Exaggerated Scare Tactics

Article from The Spectator, 2017
One of the main ways the media and some doctors discourage childbearing in fat women is by using exaggerated scare tactics. We've talked about scare tactic hyperbole before in our 2nd Annual Turkey Awards on Scaremongering and Shaming Tactics. But of course, this tactic is still alive and kicking, as demonstrated in the above articles.

This is where "experts" get to pretend that they only have the best interests of women and children at heart when they publish inflammatory articles like these. It's not weight bias, oh no! After all, pregnancy while obese has risks, right?

The 2017 article article above claims it's not stigma, it's just their concern for you. In other words, it's the medical version of Health Concern Trolling.
Don't call it fat shaming ─ there are good reasons obese women shouldn't get pregnant. Some will say that this is ‘fat shaming’, but it’s just what we do in the medical profession; the identification of risk and its amelioration. We can’t sacrifice the health of mothers and babies on the altar of political correctness.
The article then goes on to recite in scary language how obese women have higher risks for various poor outcomes, without giving any context to those risks, and without acknowledging that only fat people are targeted in this way.

Yes, women of size have increased risks of some outcomes, such as gestational diabetes, blood pressure issues, certain birth defects, and stillbirth. It serves no one to pretend otherwise, and I believe firmly that women of size should understand the potential risks. I write about these potential risks so that women of size can come from an educated and empowered point of view, and decide for themselves what to do about them.

However, it is important to have context to any discussion of risk. 

For example, a recent 2015 article is a meta-analysis of the risks of obesity and pregnancy. Again, as so many of these scare tactic articles do, it distorts risks by using relative risk ratios without any actual numerical risks. This makes the risks sound far more grave and life-threatening than they are.

For example, past research has suggested that obese women have an increased risk for certain birth defects such as Neural Tube Defects (NTDs). Scare-mongering articles always highlight the birth defects risk in particular in media campaigns because it holds so much emotional resonance. Fat women are giving birth to deformed babies! If they weren't so selfish, these birth defects could be prevented!

It's true that obese women have an increased risk for NTDs; some studies have found 2-4 times the risk for Neural Tube Defects (NTDs) in obese and very  obese women. Sounds scary, doesn't it? Yet rarely do the articles mention that double or even quadruple a very small risk (about 1-2 per thousand) is still a very small risk. Do the math. Even if there is an increased risk, less than 1% of obese women will probably have a baby with a NTD.

Expressing it in relative risk (Two times the risk! Four times the risk!) makes it sound scarier and provides a juicier sound bite for the media. But what high BMI people really need to know is what the absolute numerical risk is and what they can do to lower their risk for a NTD. [Answer: To lower the risk for NTDs be sure your blood sugar is normal before pregnancy, stays normal during pregnancy, and possibly take a higher dose of folic acid before and during early pregnancy.]

Gestational diabetes (GD) is another risk that is frequently mentioned in these articles. The risk for GD is about 3-5% among the general population, but it increases to around 15% or so in high BMI women. This is definitely a substantial increase and a potential cause for concern because it may lead to other complications.

However, reverse the statistics and you realize that about 85% of high BMI women do NOT get gestational diabetes. The risk is definitely increased but it is hardly overwhelming. Do you come away from articles on obesity and pregnancy with the impression that more than three-fourths of very fat women will NOT be diagnosed with gestational diabetes? Nor do most articles point out that even if someone develops GD, it is a very manageable condition. Most people with GD are able to control it and have healthy babies.

Yes, women of size are at increased risk for some complications, but being at increased risk does not mean that complications will happen. Many women of size have healthy pregnancies and healthy babies, a fact conveniently ignored by these media articles. They only feature stories of scary complications in order to frighten people of size out of considering pregnancy. You don't scare people away from pregnancy with stories of normal pregnancies and good outcomes.

Nor should facing potential risk disqualify you from motherhood. All kinds of women are at increased risk for complications due to various factors (age, family history, racial or ethnic status, various health conditions) but are rarely told that they have "no business being pregnant." Their risk status is acknowledged and counseling toward risk mitigation is given. The same can be done for women of size.

In dealing with women with risk factors, the focus should be on helping them have the healthiest pregnancy possible, while acknowledging possible complications ─ not trying to keep them from ever having a baby.

It's deeming people with some types of risk factors (like type 1 diabetes) as worthy of having babies despite the risks, and people with other types of risk factors (obesity) as unworthy of having babies. This suggests a bias and stigma, a real implication of a eugenics agenda, even if it is an unconscious one.

Many caregivers recognize that plenty of people of size will have perfectly fine pregnancies and healthy babies despite their size. They also know that in those who do experience complications, the emphasis should be on kind and empathetic care in helping that person towards the best possible outcome, not on scolding and judgment. Even complicated pregnancies can often have good outcomes with supportive care.

It is NOT an irresponsible act to have a baby at a larger size. Yet many of these alarmist articles imply that it is. It's NOT up to doctors to decide which patients with which risk factors should procreate. Rather, it is up to the couple to look at their particular risks and make an informed decision about having children or not. 

Reasonable risk counseling is appropriate, medical bullying through risk hyperbole is not.

It's not that we cannot discuss possible risks. Of course we can; that's an important part of the healthcare conversation. However, public health discussions about weight have gone from discussing possible risks, to making sweeping generalizations and exaggerations of risk in the public's mind, to scapegoating, scaremongering, and suspension of basic rights by healthcare professionals.

What these experts fail to realize is that weight stigma in public health campaigns often backfires and leads to worse outcomes, not better ones. Stigma affects health negatively. Increasing stigma for people of size does not improve outcomes.

When media coverage quotes "experts" who criticize women of size in inflammatory language for even considering pregnancy at a larger size, when it refuses to acknowledge that many women of size DO have healthy pregnancies and babies at higher weights, when it distorts risk, when it makes sweeping behavioral generalizations, and when it attempts to keep plus-size people from procreation through guilt and dire predictions, that IS indeed fat shaming.

Just Lose Weight First?

Headline from 2012 article in The Mirror
Some doctors are very supportive of people of size, but others are uncompromising and rigid about weight. They believe that no one should get pregnant unless they are at a "normal" BMI. From a 2017 article from the U.K.:
It is imperative that women should be discouraged from trying to get pregnant until they have attended to any excess weight.
These doctors just don't get it. Being fat and wanting children poses a difficult set of choices, and that it's not always as simple as "eat better and exercise and you'll magically lose weight and be healthy enough for a pregnancy."

Getting to so-called "ideal" weight is simply not a realistic goal for most fat people before pregnancy. Even when eating well and exercising regularly, many people of size stay fat. Even the fall-back stance of "lose just 5-10% of your weight" can have negative outcomes in real life too, as it often triggers a rebound to a weight greater than the starting point.

Doctors want simple answers, but there are none. The fact is that nearly all fat people have tried repeatedly to lose weight, and rarely is it lost permanently. Frankly, if there really were an easy, foolproof way to lose weight permanently, we'd all be skinny. It's NOT just a matter of willpower, and research shows that long-term weight loss is very unlikely.

Most fat people have lost weight time after time, only to see it come back over time. Many of us end up fatter after a weight loss attempt than before we began it. In fact, for many of us, yo-yo dieting is what actually put us in the "morbidly obese" category in the first place. For others, strong genetic and hormonal factors may be at work, making reaching that "ideal" weight statistically extremely unlikely.

When faced with people like this, doctors often suggest bariatric surgery. Weight loss surgery does reduce BMI, but research shows significant trade-offs. There are reduced risks for gestational diabetes and large babies, but also increased risks of prematuritytoo-small babies, and possibly neonatal mortality. Nutrient deficits are common and there is an increased risk for intestinal hernias; pregnancies after bariatric surgery must be monitored closely. There are no easy answers here.

Many people stop weight loss attempts because they recognize that all the yoyo-ing is hurting their health far more than it is helping it. When they do this, they are not "giving up" or "letting themselves go" but instead focusing on healthy habits instead of weight loss as a measure of health. These habits often do not lead to significant weight loss, but people are still healthier by simply emphasizing good habits and weight stability.  This approach is called "Health At Every Size" (HAES).

For some, the decision to have a pregnancy at a larger size is one chosen once we recognize that long-term weight loss is not likely to happen and if we wait to reach that "ideal" weight range, we may never have a baby.

Don't think that experts don't realize that. They do. Either they are deliberately deluding themselves about the long-term success of weight loss, or they are subtly trying to take fat people out of the reproductive pool.

Another factor to consider is that dieting before pregnancy may deplete the body's stores of vital nutrients (particularly iron), just at the time they are needed most. Many "morbidly obese" people have significant micronutrient deficiencies already; repeated dieting may be part of that. Some consciously choose not to restrict intake or undergo malabsorptive surgeries before deciding to have a baby because of this concern. We do this out of love, not out of selfishness.

Some people of size do choose to try and lose some weight before pregnancy; not necessarily down to "ideal weight" but at least a little bit in hopes of lowering risks. Everyone is an adult and gets to make their own choices. There is some research that it might improve some outcomes modestly. But is that the effect of actual weight loss or an effect of a change in habits?

On the other hand, weight loss before pregnancy can also backfire, even modest amounts. Many of these women find that once pregnant, the body rebounds with a vengeance, gaining far more weight than "should" be gained in pregnancy as the body tries to store fat for the starvation period it thinks it is in. And gaining a great deal of weight in pregnancy is not ideal for anyone, mother or baby.

There is also some research that suggests that dieting behaviors or weight loss product use just before or around the time of conception increases the risk for birth defects. So while losing even "just a few pounds" before pregnancy may seem prudent, it could have unforeseen consequences too.

The bottom line is that there are no simple solutions. The best thing a person of size can do is to focus on improving health habits before pregnancy. This doesn't have to center on weight loss. For example, regular exercise is one of the most powerful things people of all sizes can do to improve their health before pregnancy. Checking that you have normal blood sugar and blood pressure before conceiving is a very important way to improve outcomes. Starting a prenatal vitamin and extra folic acid before conception is also a good idea. Emphasizing good nutrition can also be helpful, regardless of whether it results in weight loss.

Some people of size choose not to wait till we are "ideal weight" before having kids because we know that there are risks to getting older too. Age decreases fertility and increases some pregnancy risks. We may decide that it's better to act sooner than later. 

Some of us believe that having a child at our present weight makes more sense than putting off pregnancy for years in an effort to lose weight. It's better than gambling on losing weight and then trying to keep the resultant pregnancy weight gain to "acceptable" levels, or to start out a pregnancy nutritionally-compromised from recent weight loss attempts or bariatric surgery.

Having a child at a higher weight does not mean we are ignorant about nutrition and exercise, that we are recklessly exposing children to potential risk because we are too lazy or stupid to "eat right." Many of us have very normal eating habits and do not fit the stereotypes of junk food, overconsumption, and gluttony.

Ultimately, the final choice about whether or not to lose weight before pregnancy is up to each individual. Some may decide to, and that's their choice. However, choosing not to lose weight first doesn't mean we are ignorant, uncaring, or unhealthy. Instead, for many of us, it may represent what we think is our best chance for a healthy pregnancy and baby. This is not an act of selfishness but an act of love, hard as that may be for some critics to understand.

Researchers need to STOP trying to scare and shame fat women out of reproducing and pretending that they only have the noblest of intentions at heart. They need to STOP implying that fat women are irresponsible for considering reproducing, or that the only safe way for a fat woman to have a baby is if she loses weight first. The fact is that many fat women have healthy pregnancies and babies without losing weight. Experts need to study those women and see what can be learned from them.

Intersectional Stigma

Headline from The New York Times, 2010
These media articles don't just stigmatize fatness; they often reflect other societal stigmas. This is intersectional eugenics, where women of color who are also women of size or disabled in some way are being stigmatized even more.

In the New York Times article above, the cautionary apocryphal story about obesity in pregnancy is a woman of color. Of course, it's an extreme story. The woman, in her 30s, was already diabetic with kidney issues when she became pregnant. She gained a lot of weight in pregnancy, had a stroke, and her baby was born prematurely. She is pictured mournfully sitting by her extremely small son, touching his tiny feet, in the Neonatal Intensive Care Unit (NICU), and looking regretful.

Imagine what happens when people with multiple marginalized social identities present for pregnancy care. Stigma increases even more. And it's no mistake that people with multiple stigmas are used as the "bad examples" in media articles, especially in the U.S. It's an unconscious desire to increase the "othering" of people of size in the minds of the public.

Weight stigma in pregnancy is already considerable. Caregivers report being repulsed and having less respect for people of size, along with concern on how to deal with fat pregnant women. They often assume that fat people lack "necessary skills, awareness, or motivation to manage their weight." They may view people who have become pregnant at a higher weight as irresponsible. One article notes:
Weight stigma is widespread in healthcare and can lead to anxiety, stress, depression, low self-esteem and negative body image. It can be particularly harmful during pregnancy, when women are at an increased risk of developing mental health issues and their bodies are being scrutinized more than usual. And discussions about things like how extra weight can put the baby at risk can lead to intense feelings of guilt when not handled properly.
Various racial groups, particularly African-Americans, also often experience great stigma in pregnancy. This may help explain why they have a higher risk for some poor outcomes. An excellent 2017 article from National Public Radio (NPR) explored black maternal health in pregnancy and found that blacks had far higher rates of maternal death during and after birth. The NPR article summarized (my emphasis):
According to the CDC, black mothers in the U.S. die at three to four times the rate of white mothers, one of the widest of all racial disparities in women's health...In a national study of five medical complications that are common causes of maternal death and injury, black women were two to three times more likely to die than white women who had the same condition.
According to the NPR article, the difference in maternal mortality between blacks and whites is not attributable to education, socioeconomic status, or access to healthcare. African-American women with every advantage still have poorer outcomes in general. Much of this is due to the stress of long-term exposure to racism and stigma.

What has been surprising recently is the discovery that black women are particularly vulnerable after the birth. More than half of maternal deaths occur postpartum, and people who experienced high blood pressure or cesareans are particularly vulnerable. Black women have higher rates of both blood pressure issues and cesareans. Add in chronic stress from racism and care models that chronically neglect women after birth and you have a recipe for poor outcomes.

The intersection of race and weight leads to even more stigma. The NPR article related the story of a young black Florida mother-to-be whose breathing problems were blamed on obesity when in fact her lungs were filling with fluid and her heart was failing. Getting providers to listen and take your concerns seriously is difficult, especially if you are a person of color and size.

That's why it's even more shameful when articles about the dangers of obesity and pregnancy feature women of color as their bad-mother examples; it multiplies stigma. As Abigail Saguy and Kjerstin Guys of UCLA note, articles that feature a cautionary example of a poor person of color "reinforces social stereotypes of fat people, ethnic minorities, and the poor as out of control and lazy...In the contemporary United States, body size intersects with other dimensions of inequality."

Most researchers and care providers do not consciously wish to stigmatize women of color or women of size. They want to improve outcomes, which is a good goal. But some are tone deaf. They refuse to understand that the public health campaigns they are waging around obesity and pregnancy are far MORE stigmatizing and have begun to venture into the eugenics realm.

Direct Pressure for Sterilization or Termination 

Article from The Daily Mail, 2016
The attempt to limit who can procreate doesn't just stop with scary media campaigns, hyperbole about risk, and pressure to get to a "normal" BMI first. Pressure for sterilization or termination (abortion) is another way that providers try to limit family size in high-BMI women.

We should be clear that most providers don't do this. However, it is real and it has happened. And that is inexcusable.

In the U.K. story behind the above headline, pressure for sterilization was direct and over the top. Her 5th pregnancy was a surprise pregnancy with twins, conceived despite being on birth control (which may be less effective in larger women). She was diagnosed with gestational diabetes during the pregnancy, not an uncommon finding in twin pregnancies. She was told in no uncertain terms that another pregnancy could kill her and that she needed to strongly consider sterilization:
'At 31 weeks pregnant the consultant sat me down and was blunt. Firstly he said the diabetes could cause the girls to grow quite large so I would need a C-section. And then he said another pregnancy would most likely kill me as even if I weren't pregnant, I was at a high risk of becoming a diabetic, ending up in a wheelchair and having a heart attack. As such doctors suggested I should not become pregnant again and I could be sterilised during the C-section.
And indeed, that's what this mother chose to do. The doctor was sufficiently scary in his predictions that she permanently ended her childbearing.

Sometimes the pressure is subtle, as in refusing to remove birth control devices. One Canadian woman recounted the story of her doctor who refused to remove her IUD because he felt it would be a "disaster" for her to become pregnant. Although this is not permanent irreversible sterilization, it is a de facto sterilization.

Other fat women have been pressured to have their tubes tied when they have babies. Gina Marie's story from my website shared the tale of a woman who was pressured for sterilization during labor. This is an ethical violation; ethics guidelines state that women should never be pressured for sterilization when particularly vulnerable, such as during labor. But it happened to Gina Marie anyway.

Her labor was induced early due to fear of a big baby, and not surprisingly, she ended up with a cesarean. The OB was very vocal about how she shouldn't be having children at her size, and pressured her to agree to have her tubes tied during the cesarean. When she would not agree to having her tubes tied, they tried to frighten her by exaggerating the risk of complications during the cesarean and asking her and her partner about her funeral plans during consent for the cesarean. Then they punished her by doing a classical cesarean (a giant incision, up and down, far more risky than a side-to-side incision), blaming it on her obesity, and telling her that her uterus would "explode" if she had any more pregnancies. She never did. In this case they did not succeed in directly sterilizing her but they did succeed in a de facto steriilization.

Although most care providers will not go this far or be this coercive, there is subtle pressure towards sterilization for fat women. We know there is a long and shameful history of forced sterilizations or sterilizations without consent in the United States. This is just the latest version of that, dressed up as "concern" for your health. Eugenics policies were often directed at women of color, poor women, and "disabled" women because medical authorities thought they should not be reproducing.

Although forced sterilization was not systematically applied to fat women across the board, there have certainly been stories of strong pressure for sterilization and even abortion. A number of women have written to me over the years and shared some of their stories. Care providers (or even family members) have implied that it's far too dangerous to be fat and pregnant, that they must terminate the pregnancy in order to save their own lives. Or they imply that the baby is sure to have health problems, birth defects, or be stillborn. Here are a few of the stories:
  • "I also was told I could not have kids. Then when I got pregnant I was told by various doctors for various reasons that I should abort."
  • "[The doctor] even suggested that we consider having an abortion because the likelihood was great that [problems with the baby were] going to happen....We had 2 weeks to decide about the abortion because legally you have up to 24 weeks to abort the baby." 
  • "[The doctor said:] 'No fat woman can ever have a healthy pregnancy. Besides, if you did get pregnant, I'd order you to have an abortion. But that's a moot point anyway, because you're too fat to get pregnant.' "
Another story of a fat person pressured for abortion can be found on the blog, First Do No Harm:
The doctor walked in holding my chart. The first thing she said was, “We all know you don’t want to be here.” ... She continued, “Thirty six years old and a third baby. Hmm. We all know your eggs aren’t any good any more.” [The OB] spoke on and on about why it probably wasn’t a good idea for me to have the baby and that time was running short for me to terminate the pregnancy. I finally held my hand up and said, “I am not terminating the pregnancy. Let’s just move on from there.”
Sometimes the pressure for abortion is not quite as direct. The potential for death for mother or baby is emphasized and the parents are left to fill in the dots as to what their next action should be. Sometimes providers imply that fat women will die if they try to carry a pregnancy to term, that having a baby is committing "suicide by pregnancy."  They hope that the women will be too scared to continue the pregnancy or try to conceive in the first place. Or they imply that the baby is likely to be deformed or die.
  • "I went to see a doctor today...He basically made me feel my baby is a death sentence...In his "honest opinion" I am going to die during labor/delivery or recovery."
  • "I used to go to a really Fat phobic doctor; he was so awful he told me that I couldn't even consider the idea of having another baby or I would die for sure (due to my weight)."
  • "[My doctor] was appalled when she heard I was not on any form of BCP [birth control pills] and said that "at your age and with your size" that either the baby or I would die."
  • "According to him I'm probably going to die of a heart attack sometime during my pregnancy or shortly after."
  • A reproductive endocrinologist refused to help a high BMI woman get pregnant, saying it would be unethical to do so. He says if she did somehow manage to get pregnant, "The baby would only have a 5% chance of survival."
One of the very first stories I heard years ago when I started my website was the woman who was told that she would "die on the table" while giving birth. Others have been told that they would surely have a heart attack during pregnancy or shortly after, or that they were "85% likely to die on the table" during the birth.

Although these doctors didn't directly pressure the women to have an abortion, statements implying that death is practically inevitable for a fat mother or baby are certainly going to be interpreted as pressure to terminate a pregnancy. Here is a story of a woman in the U.K. who was so frightened by the "obesity risk" talk" from her care providers that she was strongly considering termination of the pregnancy.
Please please please, can someone help me. I am 10 weeks pregnant and currently have a BMI of 35...I have had my first midwife appointment today and was told that more than 50 percent of maternal deaths in pregnancy and childbirth are obese mothers and that I will have to have special monitoring and won't be allowed to have a natural birth at the birth centre and will have to be under consultant care and be constantly monitored throughout labour (meaning no water birth, no moving around, no getting into positive positions to birth). 
I am so scared and disappointed, I feel like I am an unfit mother already and feel that the drs think I do not care about the health of my unborn baby. Now I know that this will not go down well with some people but I am considering a termination so that I can lose more weight before carrying a child (I have currently lost 70 pounds).
Here is another similar story. The woman was so scared by all the death talk around obesity and pregnancy that she was considering ending her pregnancy, even though she'd already had one successful pregnancy and healthy baby. She was particularly afraid of the risk for a blood clot (DVT).
I am pg with my 2nd child. With my first I was overweight with a BMI of 37 but had a textbook perfect pregnancy with low blood pressure, blood sugar etc and a small baby, natural birth no issues etc and everything was hunky dory. 
Fast forward 2 years and I have since suffered anxiety and depression, mostly directed towards my health. I have become a hypochondriac which is mental torture some days. I have gained a weight since I had my dd...I am so upset and disgusted with myself , I have beat myself up all day about this. I have done a lot of research the past few days and there's a lot of scary articles about how maternal death and infant death is linked to obesity, how overweight women have a much bigger chance of dying during pregnancy etc, developing DVTs (which is one of my massive hypochondriac fears).
I am terrified I am going to die during this pregnancy because of my weight that I am considering not going ahead with the pregnancy. I am losing sleep and every ache or pain I am worrying about a DVT. It has been mental torture so far and another 8 months of this seems unbearable.
Again, this speaks to the importance of presenting risk realistically. It's true that obesity is a risk factor for DVT, but the actual chances of having a blood clot are pretty small, even in a "morbidly obese" pregnant woman. Many women of similar size (including me) have had pregnancies without blood clots, but these are not the stories being promoted by the media or shared by the doctors.

Furthermore, if she is really worried about a clot, she could speak to her provider about taking a low-dose aspirin prophylactically. Some providers do this regularly with obese women; while no research on its benefit for obese women has been done, it is a choice that can be considered if she is really worried or has a strong family history of clots. She also needs treatment for her anxiety so she can deal with her fears.

Doctors may not intend to be actively promoting eugenics but they cannot overlook what the real-world effects are of discriminatory scare tactics. And shamefully, some are fully aware of these effects and employ them deliberately.

Eugenics Towards People of Size

Headline from Metro.co.uk 2016
How many women of size have had their family size limited, directly or indirectly, through medical bullying? How many people of size have decided not to have children because of the over-the-top public health campaigns against obesity and pregnancy? How many have put off pregnancy until they get to a "normal" BMI, only to find that day never comes? How many have faced pressure for sterilization or de facto sterilization? How many have considered ending their pregnancies because their doctors told them they might die? How many have been pressured to abort a wanted pregnancy because of their size?

There is more than a whiff of eugenics in these latest media campaigns, whether providers mean it to be that way or not. Some researchers have suggested that such stories "hint at so-called soft eugenic practices to keep obese women from reproducing."

From a National Post article from 2016 by Sharon Kirkey:
Canadian researchers say that amid a flurry of press about the dangers of excess fat during pregnancy, overweight and obese women are being made to feel they’re “disgusting” or “bad mothers” for putting their fetuses at risk.... 
Doctors have legitimate reasons to warn women of the complications related to excess maternal weight, they acknowledge. However, much of the obesity “risk talk” is sensationalized, moralizing and shouldn’t position heavy women as “always-already diseased and dangerous to their child,” they write in the latest issue of Social Science & Medicine. Larger women, they argue, can have perfectly healthy, incident-free pregnancies and births. 
“We’re certainly not trying to say that any of the healthcare providers that are referred to in the study is actually a eugenicist,” co-first-author, Andrea Bombak, an assistant professor at Central Michigan University said in an interview. 
“What we’re trying to say is that anytime we refuse care in these areas, or potentially limit people’s care, we could be unintentionally and inadvertently echoing some of these histories that we’ve seen in the past about who is it that society would prefer to reproduce — and who they would prefer to not have reproduce,” she said... 
Many women had positive experiences. But many others also described being made to feel as if they were “disgusting” or unfit to be mothers. 
Bravo to these researchers for calling out the hyperbole and stigma in these media articles and public health campaigns. It's time for others to take up their call.

When obese women are counseled about pregnancy risks with scare tactics and judgment, when newspaper articles use hyperbole to scare high-BMI women away from pregnancy, when obesity in pregnancy is viewed as child abuse or treated as the equivalent of drug addiction, and when women are pressured towards sterilization or termination because of their size ─ then it cannot be denied that these things begin to cross over into the repulsive realm of eugenics. 

Reproductive Policing is WRONG

Article from National Post, 2016, found here
Sadly, some medical professionals would like to prevent ALL fat women from having babies if they could. Remember the media article that states starkly that "Obese women should not have children"? This comes directly from a public health campaign started in the U.K. and endorsed by leading "experts."

Most of the time these days it's considered wrong to question a woman's basic right to motherhood, even in a mother at risk for complications. Yet reproductive policing and shaming does not seem to be equally applied among groups considered at risk for complications. It seems to be focused mostly on obese people, and worse yet, this practice is widely defended in medical circles.

Many doctors want to be the gatekeeper of who gets to procreate and who does not, and many of them particularly want to keep fat women from procreating so they don't pass along their fat genes to the next generation. A 2015 article reveals the real concern about obesity and pregnancy ─ that it will lead to more  fat people:
The kicker of all these consequences is that obesity begets obesity. "Maternal obesity is the most significant factor leading to obesity in offspring and, coupled with excess weight gain in pregnancy, also results in long-term obesity for women," the reviewers write.
Although doctors tell themselves they are just looking out for their patients, the underlying agenda here is about ridding the world of fat people. What better way than to prevent as many fat pregnancies as you can?

Because medical providers have have been taught that obesity only occurs because of sloth and gluttony, many care providers see fat people unworthy of procreating. They use whatever means they can to discourage fat women from having a family. This far exceeds their mandate as physicians, and worse, it smacks of eugenics.

Sorry, but NO ONE has the right to forbid reproduction. The government, medical authorities ─ history has shown time and again that these people should NOT be the gatekeepers of reproduction. Whether to have a baby is a decision for the woman and her partner to make and no one else.

Yes, women of size have higher risks in pregnancy as a group. So do many other groups. Fat people should not be singled out. People of size should be counseled (with compassion, not scare tactics) about their risk status and possible complications, and they should given information about how to mitigate or manage those risks. Whether or not they experience complications, they should be always be treated with dignity, respect, and support.

The ability to reproduce is one of the basic rights of people in society; the state and/or medical caregivers have NO business trying to govern that.

People should never be subject to shaming or scolding for the simple act of wanting to have a family. That principle applies just as much to people of size as to those in any other group.

Thankfully, many care providers are supportive of women of size, but the fact that some resort to extreme tactics to prevent or discourage people of size from reproducing is a terrible stain on the medical profession. This is a unique and insidious form of obesity eugenics and IT MUST STOP.