Sociology of Health & Illness Vol. 37 No. 5 2015 ISSN 0141-9889, pp. 653–667 doi: 10.1111/1467-9566.12219

‘Fat girls’ and ‘big guys’: gendered meanings of weight loss surgery Julia Temple Newhook1, Deborah Gregory2 and Laurie Twells1 1 2

Faculty of Medicine/School of Pharmacy, Memorial University, Canada Faculty of Medicine, Memorial University, Canada

Abstract

Over 80% of weight loss surgery (WLS) patients are women, yet gender is overwhelmingly absent in WLS research. This article discusses the findings of 54 interviews with twenty-one women and six men waiting for WLS in Newfoundland and Labrador, Canada. We critically examine the ways that gender shapes the meaning of WLS in these narratives. We explore gendered meanings in participants’ perspectives on their embodied experiences before surgery, social support as they decided to undergo the procedure, and their expectations for their lives after WLS. We draw on feminist theory to explain how these findings counter the dominant gender-neutral medical model of obesity.

Keywords: gender, obesity, weight loss surgery, Canada, qualitative research

Introduction Even though it’s the same surgery for a man as it is for a woman, it’s almost like it’s two different worlds. (Derek, WLS patient and customer service worker in his thirties) Weight loss (or bariatric) surgery (WLS) is increasing in popularity in affluent countries (Encinosa et al. 2011), and is frequently promoted as the pinnacle of weight loss interventions (Throsby 2009). Over 80% of individuals who undergo this procedure are women (Padwal et al. 2012, Poulouse et al. 2005). However, this gender imbalance is all but ignored in WLS research. Most WLS studies are carried out in the biomedical field, drawing on a genderneutral chronic disease model (for example, Sj€ ostr€ om 2008). Feminist research has critically examined the gendering of weight, pointing out that the very concept of ‘fat’ has long been feminised (Bordo 2004, McPhail 2009). Yet we have found no studies that specifically question why four out of five WLS procedures are carried out on women, and few that critically examine the perspectives of WLS patients from a feminist perspective (see Drew 2011, Throsby 2007). This article brings a feminist perspective to WLS through an analysis of 54 interviews of 27 WLS candidates in Newfoundland and Labrador, Canada, critically examining the ways that gender shapes the meaning of WLS in these narratives. © 2015 Foundation for the Sociology of Health & Illness. Published by John Wiley & Sons Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Maiden, MA 02148, USA

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Conceptual background Throughout Western history, up until the late 19th century, bodies were differentiated largely on the basis of social location, including class, ethnicity and gender. Yet increasingly, as relative material wealth increased, large body size and ‘excess’ flesh came to be seen as signifying personal moral inadequacy (Bordo 2004, Murray 2008). In previous eras people frequently celebrated fasting for spiritual benefits, but dieting in the ‘pursuit of an idealized physical weight or shape’ is a very recent notion (Bordo 2004: 185). At this same historical moment, conventional understandings of the body became increasingly medicalised. Physicians laid claim to ultimate authority over the knowledge of bodies, and in the prevailing discourse, health became conceptualised in scientific terms, with the body separate from the mind, and bodily processes viewed as discrete medical events to be treated with medications that target each specific biochemical process (Gustafson 2005, Morgan 1998). The precise measurement and comparison of body size also became increasingly important (Bordo 2004). In the early 20th century physicians began to distinguish between endogenous and exogenous fat. Endogenous fat was linked to an internal bodily imbalance that made one gain weight, and was associated with men. Exogenous fat was linked to overeating, and was associated with women, in whom large appetites were seen as problematic. This dichotomous conceptualisation exerted a powerful influence on thinking about obesity for many years (Schwartz 1986). Today, bodies that are large and soft are called ‘obese’ and obesity has become widely portrayed as an epidemic that threatens global health and wellbeing (World Health Organization 2012). While research has found that the average human body size has increased in recent decades (Must and Evans 2011) the implications of this trend are far from clear (Gard and Wright 2005). As McPhail (2009: 1043) writes, obesity ‘is not biologically self-evident, but a historically articulated, worked-through and worked-on category infused by power, politics, and positioning’. Scholars from numerous disciplines have critiqued the war on obesity as a ‘moral panic’ (Murray 2008) and rigorously questioned the level of health problems linked to weight (Campos et al. 2006, Cooper 2010, Gard and Wright 2005, Pieterman 2007, Rothblum 2011). Measures of weight, including the ubiquitous body mass index (BMI) have been strongly criticised as a measure of body size, not health (Padwal et al. 2011). Guthman (2013: 271) has carefully outlined the ways that the epidemiological tools used to understand obesity ‘inscribe notions of normative size that are based in averages and intensify the use of size as the litmus test for health or well-being’. The picture is further complicated by research indicating that overweight and class I obesity (a BMI of 25–34.9) are not associated with higher mortality (Mehta and Chang 2011), that larger body size may protect from certain conditions (Morse et al. 2010), and that a significant proportion of the obese population is metabolically healthy (Ortega et al. 2013). Indeed, there is evidence that many of the health risks associated with higher body mass may more accurately be attributed not to obesity per se but to confounding factors such as poor diet, lack of physical activity and weight cycling, among others (Bacon and Aphramor 2011, Campos et al. 2006, Gard and Wright 2005, Saguy and Campos 2011). From a critical feminist perspective, the medicalisation of obesity contributes to pervasive size discrimination and fatphobia (Bordo 2004, Cooper 2010, Monaghan 2008), intersecting with sexism, ageism, racism, classism and homophobia and, on a societal and personal level, exacerbating disordered attitudes towards bodies, food and exercise (Monaghan 2008, Murray 2008, Rich and Evans 2005, Rothblum 2011). Further, since medicalisation is a largely © 2015 Foundation for the Sociology of Health & Illness

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patriarchal process, women have tended to suffer disproportionately from its negative effects (Gustafson 2005, Morgan 1998). This medicalisation also takes place in a neoliberal context. Neoliberalism is an economic, political, social and moral philosophy that dominates modern society (Ayo 2012). Its main tenets, as described by Ayo (2012: 100), citing Ericson et al. (2000) are ‘minimal government intervention, market fundamentalism, risk management, individual responsibility and inevitable inequality as a consequence of choice’. In this context, the pursuit of health becomes obsessive and conspicuous, and the dominant focus is on individual choice: the responsibility of each citizen to take control of their own health by minimising risk and making the correct lifestyle and consumption choices. This ideology shrouds and conceals the complex intersection of socio-structural inequities that shape people’s lives and their health (Ayo 2012, Crawford 2006, Gustafson 2005). Feminist scholars have argued that body weight tends to hold different meanings for women and men (Bordo 2004, Chernin 1981). This article furthers this argument, demonstrating that WLS itself tends to hold gendered meanings in the narratives of women and men undergoing this procedure.

Methods In May 2011 the largest hospital in Newfoundland and Labrador began to perform laparoscopic sleeve gastrectomies (LSG): WLS procedures that reduce stomach size by roughly 80%. The present study is one component of the multidisciplinary Translational Research Program in Bariatric Care at Memorial University in St John’s, Newfoundland and Labrador. This programme is guided by a collaborative team of clinicians, researchers, and policymakers who work together to develop patient-centred research that translates into improved health care (Wolf 2008). The lead author conducted 54 interviews between June 2011 and April 2012 with 21 women and six men waiting to undergo an LSG. The participants were purposively recruited from the provincial bariatric clinic by an experienced research nurse, offered a package of information about the study, and invited to contact the nurse if they were interested in participating. As recruitment progressed the research team examined the characteristics of the sample to ensure that participants with a wide variety of ages, education levels, and occupations were represented. Additional recruiting of male participants was necessary because of their small proportion among WLS patients. In total, 27 of the 51 patients approached (53%) participated in the study. This study began with a grounded theory approach, designed to build theory from the participants’ accounts and embodied knowledge (Strauss and Corbin 1998). As the research progressed, our methodology evolved into a hybrid inductive-deductive approach, combining methods of grounded theory, particularly constant comparative analysis, with feminist phenomenological methods emphasising the participants’ lived experience and researcher reflexivity (Rice 2007). We sought to include as wide a variety of participants as possible, together with ensuring the meaningful participation of participants in developing the focus of the research, respecting the value of participants’ embodied knowledge, and attending to the complexity and diversity of the participants’ perspectives and experiences (Reid 2004). The initial in-depth interview was semi-structured, designed to explore specific research topics while also allowing participants to introduce topics, offer feedback on their care, and present ideas for future research. Eight initial interviews took place in person and 19 by © 2015 Foundation for the Sociology of Health & Illness

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telephone, as per the preference of the participant, and lasted from 45 to 90 minutes. Signed written consent forms were collected by the interviewer or posted by letter. All 27 initial interviews were digitally recorded and transcribed verbatim by a professional transcriptionist. The interviewer then summarised the transcript into a one-page interpretive summary. Once this was completed, the second interview was conducted by telephone and lasted from 10 to 40 minutes. The follow-up interview occurred within 1–3 months of the initial interview in order to ensure that the participants recalled the discussion. The interviewer read the summary to the participants, giving them an opportunity to comment, and offered them a paper copy of the summary. The follow-up interviews were intended to clarify any gaps in the initial interview and to give the participants further opportunities to question the researcher and to actively participate in interpreting the interview data. This feedback formed part of the co-creation of the research findings (Guba and Lincoln 2005), so that the participants’ ‘selfrecognition’ (Bloor 1978: 549) would improve the trustworthiness and credibility of the research (Denzin and Lincoln 2005). The participants ranged from 26 to 64 years of age, with an average of 45.3 years. Six participants (22%) had a high school education or less, 15 (56%) had some post-secondary education and six (22%) had a university degree. As is representative of the study area, nearly all the participants were Caucasian (26, or 96%, while one was Aboriginal). Most were married or living with a common-law partner (18, or 66%), had children (21, or 78%), and were working full time (16, or 59%). We use pseudonyms to distinguish the participants, along with their general age range and type of occupation. These details are intended to give a sense of the individuals’ particular life circumstances without providing any potentially identifying information. The analysis began with the first interview. Two coders (Temple Newhook and Gregory) read and re-read the transcripts and interpretive summaries and identified and coded emerging categories and themes, while exploring similarities and differences among them and between individuals and groups of individuals (Strauss and Corbin 1998). The categories and themes were linked to theoretical constructs. The emerging categories, properties and descriptors were also analysed by an independent research consultant. The lead author then conducted a secondary analysis, the focus of this article. This analysis concentrated on the importance of gender-based differences in the participants’ narratives. The themes were coded electronically and then organised into separate documents. Four primary themes were identified in which gender-based differences were prominent: histories of weight loss and gain, living in a fat body, support for the decision to undergo WLS, and expectations of life after WLS. The first theme, which deals with participants’ perspectives on the causes of their weight gain, is discussed in a separate publication (Temple Newhook et al. 2013). Ethical approval for this study was given by the Health Research Ethics Authority at Memorial University. Limitations The sample for this study included just six men, and there remains a need for research involving the perspectives of a wider variety of male WLS patients. The participants were also not questioned on their identity, in terms of their sexuality or status as cis or transgender. Given the strongly context-dependent nature of the meanings of body size (Monaghan and Malson 2013), there is a strong need for further research with participants with a wide variety of sexual and gender identities, ethnicities, (dis)abilities and cultural and socioeconomic backgrounds. © 2015 Foundation for the Sociology of Health & Illness

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Results We discuss three particular areas of gendered difference in the participants’ narratives that touched on the meanings of WLS. We interviewed the participants while they were waiting to undergo WLS and we organise our findings chronologically within the decision-making process: (i) before: participants’ gendered perceptions of life in a fat body; (ii) during: social support for their decision to undergo WLS; and (iii) after: expectations of life post-WLS. Before: life as a fat girl or a big guy Women and men both talked extensively about their perceptions of the physical and psychological challenges of living in a large body. However, the participants made it clear that gender matters in the lived experience of obesity. It is a qualitatively different experience to live as, in participants’ words, a fat girl or a big guy. Throughout the narratives, most participants referred to their own bodies as large, big or heavy. However, when they referred to how they felt defined by others, there was an important difference. Women talked much more about being identified as a fat girl. Men, however, noticeably avoided the word fat and focused on the much more socially acceptable identity of big guy. The women participants often described feeling completely publicly defined by a fat girl identity (Rice 2007), and described their weight as profoundly affecting their sense of self. Deirdre, an educator in her forties, remembered, ‘Even in elementary school, I was always the fat girl’. Women who had previously been slim spoke about how much their identity had changed as the size of their bodies increased. Karen, a homemaker in her fifties, admitted that she had turned her hatred of fat inwards (Rothblum 2011) as she had gained weight: I used to see fat women and get really disgusted by them. Even now . . . I wear nothing but black. I have a really hard job shopping for clothes . . . I don’t like the way fat women look in bright colours . . . Even now, I talk about fat people like I’m skinny, right? I’m just horrible with it. I just hate it so much. For participants, being identified as fat is in effect a ‘spoiled identity’ (Goffman 1990: 14) that links the external appearance of their bodies with their individual character. As Bordo (2004: 193) writes: Increasingly, the size and shape of the body have come to operate as a marker of personal, internal order (or disorder) – as a symbol for the emotional, moral, or spiritual state of the individual. Women in particular talked about feeling that they had to compensate for their sense of disgrace for having a fat body by putting extra effort into their personal character. Carolyn, a professional in her fifties, explained that she tried to compensate for her large body by focusing on other aspects of her appearance: [Friends] say, ‘I don’t even look at that you’re a bigger girl because you are always dressed so nice’ . . . I have everything matching, my shoes, my purse . . . I feel that I compensate sometimes, because of my weight, so I go that extra mile to dress nicely. Faith, an educator in her forties, talked about trying to compensate for her weight in other ways: © 2015 Foundation for the Sociology of Health & Illness

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It is hard, but I always feel I have to apologise. So I have to make sure that I do things better, or I have to be nicer than other people. I have to be more competent than other people. I can’t complain about things because I have to compensate for my size. Fat itself is coded as feminine, yet thinness is simultaneously held up as a standard of femininity (Bordo 2004, Monaghan and Malson 2013). The participants in this study negotiated embodied femininities and masculinities in this context. The younger women in the study spoke with emotion and at length about their appearance. Natalie, a youth worker in her twenties, talked about how hurt she was to overhear her mother’s friend saying: ‘Oh, she would be so gorgeous if she could just lose the weight’. A small number of women said they were deeply concerned about being unattractive to their spouse. Faith said, He’s body beautiful . . . I think: ‘Oh my God, why are you with me?’ . . . I have always been a bigger person, but the more I feel bad about myself, the more I am not available to do stuff with him. I would never let him see me naked. I’m very worried. If he’s in bed and I’m getting ready to go to work, I go in a different room. I would never get dressed in front of him. Jennifer, a manager in her forties, said ‘I’m an attractive girl, if you can see past the weight. That’s the hard part’. Jennifer’s comments frame her large body as an obstacle, so that any beauty that is present can only be seen by looking past her weight. Women both reinforced and resisted dominant constructions of large female bodies as problematic and in need of improvement (Bordo 2004). Heidi, a customer service worker in her thirties, expressed frustration with a ‘stubborn’ female relative who resisted pressure to disparage her body shape: She’s all hips and legs like me . . . I try to motivate her, but she loves herself the way she is. ‘I wouldn’t mind losing weight’, [the relative] said, ‘but I still like me the way I am’. Vanessa, an office worker in her thirties, identified herself as just such an exception among the women WLS patients: I have a very positive self-image. I’m happy with myself. I have a very strong relationship with everyone around me. I’m doing well in my career. So it’s nothing about self-image why I’m [undergoing WLS]. Not a single woman in this study described her body as strong or powerful. In contrast, the men could readily draw on a discourse of a big male body as tough, robust, and strong (Monaghan 2008). Andrew, a personal care attendant in his forties, said, ‘Even though I’m big, I’m also muscular . . . I’m still fairly strong . . . excellent shape, for the size of what I am’. As Monaghan (2007: 587) writes, citing Goffman (1968), for men, ‘the meanings associated with “larger” male bodies . . . need not “spoil” masculine identities’. Men often talked about being comfortable with bodily bigness as long as it could be associated with masculine muscularity, but also negotiated with and resisted the association of bodily fat with feminine weakness or excess (Monaghan 2008). Andrew also mentioned that children sometimes commented on his body, saying, ‘You got a big belly!’ but was quick to add that it did not bother him. Chris, a manager in his thirties, reflected on the difficulties he had talking about his body: © 2015 Foundation for the Sociology of Health & Illness

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I just want to be able to wear nice clothes, dress fine, and be comfortable . . . I probably wouldn’t go swimming all day long [or] be sitting around with [my] shirt off . . . I always said I didn’t enjoy it, but I think I didn’t enjoy it because of the weight. In Monaghan and Malson’s (2013: 311) words, the participants framed fatness as ‘irrelevant or peripheral to masculine worth’. By discussing their appearance and their feelings about their bodies, male participants struggled with the prevailing discourse of masculinity in which men are not supposed to reveal their emotions or show concern for their physical appearance (Courtenay 2000, Monaghan and Malson 2013). In a neoliberal context health is understood as being primarily an individual responsibility and as responsible citizens, both women and men are expected to control and care for their bodies (Ayo 2012, Crawford 2006, Gustafson 2005). However, self-care is strongly coded as a feminine project. While women are able to draw on their emotions to account for their pursuit of self-transformation through WLS, men are expected to distance themselves from the emotional aspects of self-care (Brenton and Elliott 2014). During: support for the decision to undergo weight loss surgery The participants’ narratives give a description of strongly gendered social support networks for those undergoing WLS. Women tended to describe deciding to undergo WLS in spite of the opposition of their (male) spouses. In sharp contrast, men tended to credit their (female) spouse with their decision to undergo WLS, and said they depended heavily on them for support. (As noted above, all participants who reported having a spouse reported being in a heterosexual relationship.) Overall, the WLS support networks for both men and women were almost entirely female. Four of the five married male participants said their wives were heavily involved in their decision to undergo WLS, taking on the role of researching WLS and encouraging them to consider the procedure. Both Chris and Michael, a disabled labourer in his sixties, stated that their wives had convinced them to consider WLS after a close female relative had undergone the surgery. These men described the process of deciding to undergo WLS as a joint decision: always using the word ‘we’ rather than ‘I’. For example, Michael said: We were talking about it and . . . we heard tell of [Surgeon] going at it so we went to Doctor] and he told us he was going to make an appointment to see [Surgeon]. Such accounts of men’s health beliefs and health-related behaviour are demonstrations of masculinity (Courtenay 2000). The phenomenon of men delaying seeking health care is wellknown in health literature, and research has shown that men’s health behavior is strongly linked to a discourse of masculinity that values toughness (Courtenay 2000, Dolan 2011). This phenomenon is shaped by social class (Del Mar Garcıa-Calvente et al. 2012), as well as by the presence or absence of a female spouse (McEvoy and Richardson 2004). Considering the association of weight loss and WLS with femininity, these men may have attributed the decision to undergo WLS to their wives as a way of establishing a credible masculine identity (Courtenay 2000), as also noted in a study of women and men’s use of complementary and alternative medicine (Brenton and Elliott 2014). As Robertson and Monaghan (2012: 154) write, ‘many men may be “giving over” responsibility for their health to female partners or relatives in a manner that confirms and maintains the traditional gender roles of both’. In stark contrast, the women participants overwhelmingly reported that their husbands were opposed to their decision to undergo WLS. Many said their husbands were emotionally © 2015 Foundation for the Sociology of Health & Illness

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supportive but preferred them to accept their bodies at their current size. Faith explained that her husband wanted to support her but did not support her decision to undergo WLS: He would like me to be happier. He just thinks I can do it myself in terms of accepting who I am, what I am, and how I look . . . He doesn’t really think that I need to go that extreme. Una, a homemaker in her fifties, said her husband was nervous about the potential complications of WLS and he ‘would rather me be like I am if I was healthy . . . [but] he knows that I can’t live like I am now either’. Other women perceived their husbands as being very unsupportive. Elsie, a homemaker in her fifties, made sure to schedule her telephone interviews for times when her husband would not be at home, explaining that she was not comfortable discussing WLS in his presence. Deirdre and Penny, homemakers in their thirties and Brenda, a caregiver in her forties, said that their husbands were often unsympathetic and did not understand their struggles to lose weight. Brenda said her husband ‘is one of these people: “you should exercise, change what you eat”. . . I said, “That’s fine for you, but I’ve tried and it doesn’t work”’. These spousal reactions reflect the prevailing discourse on weight focused on simplistic notions of ‘energy in – energy out’ (Pearce and Witten 2010) – notions that ignore the complexity of the lived experience of weight gain (Temple Newhook et al. 2013). These comments also reflect our society’s negative culture of ‘knowingness’ about fat bodies, which positions us all as ‘lipoliterates’ (Graham 2005: 178) who read multiple levels of negative meaning into fat, including assumptions about a person’s character and health (Murray 2008). Both male and female participants said they depended more heavily on female than male peers. Women tended to say their friendships with other women offered them emotional support, partnership for weight loss attempts, and support for the WLS experience. Annie, a retired caregiver in her sixties, had decided to have WLS after two of her female relatives had undergone the surgery. Linda, an entrepreneur in her forties, talked about convincing a female relative to undergo WLS. Carolyn said: One of my sisters is about the same size as me. I have a very close friend, she can’t wait. When I have [WLS] done and everything is going good, they want to have it done too. Women also talked about the importance of meeting other WLS candidates through inperson and online peer support groups. While some participants talked about problems with jealousy over the different times they had to wait for surgery or weight loss, many greatly valued the relationships they had established. Zoe, an office worker in her thirties, said: There’s one girl, I talk to her a lot. She’s an awesome support group and I felt like she feels the same way that I do . . . she will know exactly what I’m going through. Women’s descriptions of developing a support group of female peers for WLS reflected and reinforced the dominant discourse of weight loss as being a feminine social activity (Bordo 2004). The dominant associations of weight loss with femininity extend to WLS, which is framed in participants’ conversations as another weight loss tool (Throsby 2008). These gendered associations may be further strengthened by the heavy marketing of WLS to women (Woolhouse et al. 2012). In contrast, men tended to display less interest and even disdain, for WLS support groups. The men showed they were very reluctant to talk to other men about WLS or weight loss in © 2015 Foundation for the Sociology of Health & Illness

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general. While there has been a public emphasis on men’s weight in some jurisdictions, such as the UK (Monaghan 2008), this is much less so in Newfoundland and Labrador. Andrew said that it was difficult to find a group of male peers with whom to discuss weight loss issues, and he was discouraged when he found that the weight loss support programmes he sought were heavily dominated by women. He observed that attending weight loss programmes seemed to be a social outing for women, whereas he often felt isolated in such a setting: There’s not a lot out there for males . . . The advertising [for weight loss programmes] is more geared towards women . . . I wasn’t comfortable with it . . . if you had a group of women who goes out and they chat . . . it would be more of a social thing . . . For me, I used to have to go to Weight Watchers myself. Derek, a customer service worker in his thirties, said that his male peers were uncomfortable when he brought up WLS: ‘it’s usually the men giving you a hard time about it’ and telling him, ‘Just go for a jog, b’y!’ For men, the profoundly gendered connotations of both weight loss and WLS may make it more difficult to seek and find peer support when undergoing WLS. Men’s attempts to seek emotional support may also be made more difficult by the dominant discourse of masculinity discouraging men from help-seeking behaviour (Courtenay 2000, Dolan 2011). After: expectations for life post-weight loss surgery In terms of expectations for their lives after surgery, appetite was an issue of particular importance to the participants of this study. As explained in the methods section, the procedure these participants were to undergo reduces the size of the stomach to a fifth of its normal size. In doing so, an individual’s appetite is drastically reduced, both through the reduction in stomach capacity as well as through the removal of parts of the stomach that produce ghrelin, the hunger hormone (Bohdjalian et al. 2010). The participants’ description of their anticipation of this reduction in appetite was noticeably gendered. In Western society, nibbling, eating small portions and dieting are seen as feminine activities, while large, hearty appetites are coded as masculine (Throsby 2007, Woolhouse et al. 2012). The women participants tended to describe their feelings of shame in regard to their appetites. Jennifer described her frustration with and shame of her current (pre-WLS) appetite, saying, ‘I would like to get my mouth sewed up or my jaw wired or something’. The women also expressed more positive feelings than men about the upcoming reduction in their appetites. Deirdre said she was excited about being able to eat tiny meals after WLS: ‘feeling full with just a little bit of food, that is going to be amazing to me’. Women also tended to express confidence that after WLS, they would not draw attention to themselves when consuming tiny meals in public, as most people would assume they were engaged in what Throsby (2008: 127) called the ‘normatively feminine practice of dieting’. Bordo (2004: 206) described the female appetite as a metaphor for female desire and argued that the symbolic and practical control of female appetite is ‘continually constructed as a problem in patriarchal cultures . . . and internalised in women’s shame over their own needs and appetites’. She argued that Western society holds up ‘the tantalising (and mystifying) ideal of a perfectly managed and regulated self, within a consumer culture which has made the actual management of hunger and desire intensely problematic’. In this context, we can see the appeal of WLS in offering a potential solution to this mystifying ideal through a tangible, physical control of women’s appetites. © 2015 Foundation for the Sociology of Health & Illness

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From the perspective of the men in this study, however, a discourse of robust masculine appetites led to its own problems in the face of the appetite-suppressing effects of WLS. Chris was concerned that his co-workers would notice the change in his eating habits, particularly when following the required liquid diet for WLS. Derek stated outright that he believed WLS was more challenging for men. Drawing on this discourse associating appetite with masculinity, he said, ‘I probably eat double the calories of the average woman’. He elaborated that men have much greater appetites and physical activity levels than women, and stated his conviction that the change to a reduced post-surgery diet requires much greater changes for men than for women. In this way, Derek and other male participants ‘attempted to shield their threatened masculine identities by contrasting their own bodily bigness, corporeal concerns and embodied practices with those of women and girls’ (Monaghan and Malson 2013: 304) Further, by engaging in such gender in/equality men identify themselves with a masculinity that is unthreatened by fat (Courtenay 2000; Monaghan and Malson 2013). Finally, the participants spoke at great length about their hopes and expectations for how WLS would change not solely their stomachs and their physical bodies, but their entire physical, mental, emotional, and social well-being. They talked about ‘a new life’ and ‘a new beginning’, about being reborn as the person they always believed they should be. However, there were marked differences in participants’ expectations in terms of gender and age. The participants described a wide variety of health experiences, ranging from those who self-identified as healthy and active to those who were suffering chronic health problems and were nearly bedridden. Mobility, physical health improvements, and the prevention of future health problems were a key focus for all participants, but particularly for the participants over 50. Una, who was living with a serious chronic illness and mobility limitations, stated, ‘I have no expectations about being a skinny, skinny person. I just want to be healthy’. Chris, two decades younger and comparatively quite physically active, said he just wants: To be able to do more. Obviously, you got the weight on of two people. You get tired easily. You don’t have the energy you used to have . . . After 5 hours [working] now I’m ready for a nap. I’m only [in my thirties], so it’s time to do something now before it gets too late. Here, Chris drew on a neoliberal discourse of individual responsibility for health, positioning himself as a responsible agent for his own health, working to relieve the healthcare system ‘before it gets too late’ – from the ‘burden’ of his future ill health (Ayo 2012, Gustafson 2005). These findings echo those of Tischner and Malson (2012), who interviewed 18 women who self-identified as large and found that these women reproduced dominant constructions of unhealthy fat even as they identified themselves as healthy and knowledgeable about health. This apparent contradiction revealed a struggle between two conflicting positions: as a responsible neoliberal citizen taking control of one’s own health, and as a fat person who had failed to control their own body and thus risked poor health. Male participants tended to express their scepticism of the BMI definition of normal weight (Monaghan 2007) and to indicate that they embraced their own definition of well-being based on their own judgement of how they felt in their own bodies. Andrew said that he would be happy to lose just 50 pounds, because he believed it would make a big difference to what he was able to do. Brian, a professional in his forties, said: I have a goal in mind that I want to be back to my weight when I was out of university, which I still know is not an ‘ideal’ on the scale for me, but it is ideal from the perspective of what I believe to be able to have a reasonable quality of life and be able to do more of © 2015 Foundation for the Sociology of Health & Illness

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the things I could do in the past. I’m not expecting to become a marathon runner. I wasn’t back then. But could I get back into racket sports a little bit? Maybe I could. Could I walk more? In contrast, young women tended to express a desire to reach a weight lower than health professionals had suggested (echoing the findings of Heinberg et al. 2010). Heidi said: My doctor says with the surgery I can get down to 200, but that’s not good enough to me. My goal weight is definitely lower than that. I would be happy at 170, but I wouldn’t mind being 150 or 160 . . . I would be completely, utterly in my glee and happy. Research indicates average weight loss at 6 years after WLS is 50–60% of ‘excess weight’ (Himpens et al. 2010) but younger female WLS patients tend to want to strive for a BMI-measured normal weight (Walfish and Brown 2006). While normal is used as a medical term, in popular culture it is a term wrapped up in standards of beauty and morality (Throsby 2008). The irony is that, as Throsby (2008) writes, while WLS is extraordinary, it is also constructed as a way of becoming ordinary, by investing the individual with normative ability to survey and discipline the body. Overall, while men tended to talk about emotional and social health in terms of moderate improvements, women tended to draw on a discourse of WLS as complete transformation (Throsby 2008). Heidi said: I said to my husband, ‘By the time this is done, you’re going to be going to bed with a new woman!’. . . I’m going to have new boobs, new stomach, new arms . . . I’m going to be the way I picture ‘me’ [when I close my eyes]. Penny explicitly stated her hopes that the physical changes in her body brought about by WLS would transform her emotional health as well: ‘I’m hoping actually . . . that if I lost all of this weight, all the [emotional] baggage would go too’. Faith carefully articulated her hopes for emotional transformation: I think that if I could be happier with myself in terms of how I look . . . then I would accept myself better. I wouldn’t always feel guilty or inadequate . . . So I’m hoping [WLS] would allow me to become the person that I think I should be. Women participants often expressed the hope that WLS would allow them to become a more authentic version of themselves. Throsby (2008: 120) argued that the ‘new me’ that WLS patients strive to uncover is not directly a transformed (slimmer) body, but a rebirth of the self as a responsible individual who is able to control and restrain their consumption and their body. This discourse promises renewal, but it is a slippery and contingent identity claim that comes at a price, requiring new techniques of disciplining the body and locating any blame for potential failure of WLS squarely on the shoulders of participants themselves (Throsby 2008).

Discussion and conclusion In summary, this study has revealed that WLS holds strongly gendered meanings in the narratives of WLS patients, including their embodied experiences before WLS, social support as © 2015 Foundation for the Sociology of Health & Illness

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they decided to undergo and then waited for WLS and their expectations for their lives after WLS. Aphramor (2005) argued that in present-day Western society: The current weight-loss schema helps to naturalise a fatness discourse that not only represents large people in offensively stereotyped ways but also fails to integrate people’s lived experience as gendered, situated bodies in an inequitable world. This article attempts to address the lack of attention in WLS research to the gendered, embodied experiences of people who are deciding to undergo WLS. The participants drew on dominant gendered discourses about bodies and appetites that shape WLS itself as a feminine surgery, closely following normatively feminine practices of food and body surveillance. Men struggled against the feminine associations of WLS by contrasting their own embodied perspectives and practices with those of women. Most WLS research, however, treats WLS as a gender-neutral surgical procedure. This gender-neutral focus is linked to the powerful influence of the biomedical model of obesity that frames obesity as a chronic disease (Centers for Disease Control and Prevention 2013). A perceived advantage of this chronic disease model is that it positions obesity as a bodily dysfunction, as opposed to a personal flaw. The participants sometimes privileged such medical understandings of obesity in their narratives, using the language of chronic disease to resist the ubiquitous moral blame for their weight (Murray 2008, Throsby 2007) while simultaneously accepting its fundamental presumption that higher body mass is inevitably pathological. Throsby (2008) has pointed out that from a Foucauldian perspective (Foucault 1979), this tension reflects the inevitably intertwined nature of power and resistance and draws attention to the contradictory status of the WLS patient as both object and subject of the war on obesity. The neoliberal chronic disease model of obesity is problematic in that it continues to individualise and medicalise body size, overlooking social context and limiting wider discussions of health and wellbeing by equating large body size with illness and dysfunction. In a similar way, Bordo (2004) argued that it is highly problematic to understand eating disorders predominantly within the terms of the medical model. She asserts that while the medical model does not engage in cultural criticism, the cultural and social context are essential to understanding eating disorders – since bodily meanings are constantly being produced by the individual, the cultural context and the clinician. Bordo’s theorising of eating disorders may be particularly poignant for the study of WLS, because in a sense, WLS itself sets up the body for a kind of permanent eating disorder – forever subjected to careful surveillance and control of the timing, portioning, and combinations of food and drink. Drawing on Foucault (1977), Bordo argues that our society’s preoccupation with fat, dieting, and slenderness: May function as one of the most powerful normalizing mechanisms of our century, ensuring the production of self-monitoring and self-disciplining ‘docile bodies’ sensitive to any departure from social norms. (1977: 186) A focus on the ‘pathology’ of eating disorders and of ‘obesity’ diverts attention from the ways in which the management of bodies and food serves a normalizing function that reproduces gender. Throughout Western cultural tradition, Bordo (2004: 205–6) writes, self-control is coded as male, and ‘[w]omen’s desires are by their very nature excessive, irrational, threatening to erupt and challenge the patriarchal order’. In this cultural context, slenderness has become a metaphor for the control of desire. In Victorian times, she points out, corsets were © 2015 Foundation for the Sociology of Health & Illness

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used to contain women’s bodies and reproductive femininity from the outside. Today, women take on the mission of slenderness no less forcefully, but internally, through self-management, with all its deceptive promise of freedom and empowerment (Bordo 2004). Men likewise negotiate a powerful discourse of self-management, while balancing this with the tension of a discourse of dominant masculinity that repudiates self-care (Brenton and Elliott 2014, Courtenay 2000). WLS patients take the normalising project one step further, striving to manage their bodies through internal, surgically altered controls. Despite medical terminology describing their bodies as extreme or severe, women and men undergoing WLS are engaged in the same gendered, normalising bodily project that prevails throughout Western society. We are all pressed upon to control and contain our gendered bodies. As Bordo (2004: 212) writes, ‘whether externally bound or internally managed, no body can escape either the imprint of culture or its gendered meanings’. Address for correspondence: Julia Temple Newhook, Patient Research Centre, HSC-1407, Faculty of Medicine, School of Pharmacy, Memorial University, St John’s, NL A1B 3V6, Canada. E-mail: [email protected].

Acknowledgements We wish to thank the 27 participants in this study for generously sharing their perspectives with us. We also wish to thank the members of the Translational Research Team in Bariatric Care at Memorial University. Finally, we wish to acknowledge the financial support of the Health Care Foundation, St John’s, Newfoundland and Labrador, Canada.

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