Exploring Media Representations of Weight-Loss Surgery

The stereotypical fat person: Positioning the other

Essential to positioning the fat body as diseased and a failed citizen within the discourses of biomedicine and benevolent government was the construction of the obese individual as other: abnormal, pathological, and deviant. The construction of a fat stereotype functioned to securely position the obese individual in the realm of the abnormal or pathological. Particular images were evoked to bolster existing stereotypes, such as the classic “couch potato” and the indiscriminate consumer of “unhealthy” foods such as hamburgers, ice cream, and French fries. For example, one author who discussed why surgeons were currently in demand in Alberta drew on such stereotypes to reinforce the important role of the surgeon (and the medical establishment): “Most surgeons require patients to demonstrate a change in lifestyle and eating habits before the operation since they won’t be able to consume hamburgers, french fries and ice cream indiscriminately post-surgery” (Sinnema, 2010a, p. A1).

The language used reinforced popular stereotypes; obese individuals were depicted as a lazy, unpopular, and unhealthy. For example, when discussing the problem of rising obesity rates, John Stanton, founder of a store that caters to joggers, was quoted in one of the articles as having said,

For many Albertans, the prospect of jogging around the block conjures up memories of junior high school gym class, where the jocks acted like bullies and teachers openly ridiculed the fat kids. The impulse to exercise can turn into a sudden craving for comfort food. (Spencer, 2005, p. E13)

This sentiment was echoed in other articles. One author lamented that individuals needed to take more responsibility for their own health, saying, “There is probably a degree of laziness that results in many resorting to high-calorie fast food as their staple diet. In order to eat healthy, we have to sweat a bit by the stove as well” (Milanovich, 2005, p. A19). Additionally, we see from this excerpt that notions of personal control regarding one’s weight take work. Rhetorical devices such as these reinforce the subject position of the fat stereotype as lazy, out of control, and irresponsible.

Obese individuals were consistently depicted as not fitting in and thus not being “normal,” as illustrated in one article about a woman who had overcome her out-of-control, deviant lifestyle behaviors as a result of having had WLS: “[She] still has the occasional chocolate cookie, but she’s come a long way from the time she could no longer tie her shoes or go to a restaurant without making sure the chairs didn’t have armrests” (Sinnema, 2010b, p. A1). By establishing that alteration was required because one’s body and behavioral practices did not fit “the norm,” the obese person’s position as other was firmly established within the discourse. Persons requiring surgery were also understood as literally not fitting into ordinary facets of society that “normal” people take for granted, such as the restaurant furniture; figuratively they did not fit because they were understood as “other” when compared to those with a “normal” weight. In turn, WLS emerged as providing the promise of normalcy and freedom from one’s transgressions.

The majority of stories and examples provided in the articles depicted women as the primary target of WLS. All but one of the 13 articles that included gendered references to WLS candidates or obese individuals focused on women, with the exception also including a man as an example. Additionally, one article did not make any references to women, and relied instead on the example of a man who had undergone WLS. Five article titles included a reference to women, such as “Woman overcomes physical and social hardships of obesity” (Capital Health, 2009c), and “Wining at Weight Loss: A Woman’s Story” (Capital Health, n.d.). None of the titles included any references to men.

Not only did the majority of examples of obesity and WLS depict women, but CDA allowed us to identify and explore the ways women were portrayed. The authors relied on a hetero-normative construction of women’s realities, implying a particular view of women’s sexuality. To accomplish this, authors used terms such as boyfriend, husband, and babies in human interest stories to reinforce heterosexuality. For example, a woman who had undergone WLS at the new Weight Wise clinic was quoted in one of the articles as having said, “Choosing to have the surgery was a matter of health. ‘I wanted to be able to spend more years with my husband’” (Capital Health, 2009a). In another article about the rapidly growing Weight Wise program, a bariatric surgeon was quoted as follows:

For the right patient, the surgery can provide a second chance at life, Davey said. “When you take a 28-year-old woman who’s 450 or 500 pounds, and you get her weight down to 180 pounds, she gets a life. She becomes employable, she can walk, she gets a boyfriend, maybe a baby.” (Ruttan, 2005b, p. A1)

By referring to boyfriends, husbands, and/or babies within the stories of WLS, women were often promised a life transformation and access to the happy-ever-after story. This transformation was presented as an opportunity for women to realize their “true” calling as women—marriage and/or “landing” a man. When discussing a former patient and her life postsurgery, a physician recounted, “’We had one patient who lost about 130 pounds, divorced her husband and married her fitness instructor, and is moving to Los Angeles,’ he said. ‘That’s the kind of lifestyle changes that occur’” (Ruttan, 2005a, p. A1).

This highly gendered rhetoric was woven deeply into a fairy-tale narrative that positioned obese women as helpless, unhappy, and less sexually desirable, also reinforcing the subject position of obese stereotypes. Moreover, surgeons emerged as saviors: heroes rescuing fat women from their despair and unhappy lives. The masculine language used to describe the surgery, often drawing on war or sports metaphors (e.g., “tackles toughest cases”; “battled weight”; “fight against obesity”), and used in conjunction with terms such as husband, marriage, and boyfriend, reinforced this gendered fairy-tale narrative.

In three of the articles, frequent references to the role of mothers in obesity prevention, causation, and treatment also reinforced gendered notions concerning WLS. Such framings implicated women as responsible beyond their own bodies for the lives of their unborn children. Women’s responsibility in motherhood was understood to begin with pregnancy, as exemplified in one article concerning the effects of women’s obesity on their unborn children. A physician noted, “Addressing childhood obesity starts with care during pregnancy, and young people who are already obese or at risk need treatment early on” (Collison, 2008, p. G4). The author of one article focused on research related to obesity and pregnancy, discussing the benefits of WLS for reducing the risks of maternal obesity and their effects on the unborn child. According to the researcher interviewed, “This [obesity] is something that perpetuates through generations. . . . If a female is born from a pregnancy complicated by obesity, that impacts her ability to have a healthy pregnancy subsequently” (Collins-Lauber, 2009, p. B3).

Although women were clearly the focus of most examples within the stories, men were not exempt from their own version of the happily-ever-after story, with one of the authors drawing on similar notions of hetero-normativity by using terms such as wife:

Since [the surgery], the patient’s relationship with his wife has improved, he regularly goes to the gym and he no longer has to take insulin. His high blood pressure has disappeared and the man even wants to find a more active job, rather than his current one of sitting all day. (Sinnema, 2008, p. B3)

In contrast to the fairy-tale narrative concerning women, what we see in the above example is that the narrative did not position weight loss as key to men’s “true calling,” defined for women as finding a mate or having children. Instead, men’s promise for a better life related to better health and improved vigor, both of which feed into the notion of men’s identity being dependent on hard work, physical strength, and fortitude. Such rhetorical strategies establish WLS as a solution for both men and women, but do so in gender-specific ways, reinforcing limited notions and stereotypes concerning gender and health.

The ideal patient

The ideal patient subject position provided a framework of dietary and exercise behaviors and personal responsibilities (i.e., notions of obese individuals lacking personal control were reinforced) that potential surgical candidates were expected to comply with to be “good” and worthy candidates of WLS. For example, one article in which the author discussed the increasing demand for and incidence of WLS at the Weight Wise clinic outlined self-monitoring techniques that patients needed to engage in to be worthy of WLS: “[Before surgery,] patients must keep a journal of what they eat and wear a pedometer to measure their activity level” (Ruttan, 2005a, p. A1). Another article outlined similar techniques, with the author describing technology and devices that patients could use to become more responsible and therefore better candidates for WLS:

To keep track, she was required to wear a pedometer and track her steps and food intake. . . . “I plan my meals, eat a healthy diet, and go to the gym three to four times per week. I take only one prescribed medication, down from several prior to surgery,” [the patient stated]. (Capital Health, 2009c, para. 12)

The use of directive language—such as words like must and need—and the focus on self-surveillance activities (e.g., wearing a pedometer, keeping a journal) served to remind the reader that the ideal patient had to earn access to WLS through these self-control techniques. Only when compliant—when performing as the ideal patient—was an individual deserving of medical intervention. Another article was focused on the success story of a woman who “won at weight loss” after going through the Weight Wise program:

During the wait, she lost 30 pounds through Weight Watchers Online. Then . . . she underwent nutritional counselling, learned what to expect from her surgery, and found out how she was going to manage her new way of eating. After dietitian Carlene Johnson-Stoklossa created a weight loss plan for her, she lost another 17 pounds. (Capital Health, n.d., para. 3)

Individuals enacting the subject position of the ideal patient were expected to continue with the performance and self-surveillance even after the surgery. The ideal patient thus accepted a life sentence of deprivation, self-monitoring, and hard work to control a potentially out-of-control obese body. A woman who underwent surgery explained, “I don’t even feel like I had surgery. . . . I can go to a restaurant and share a kids’ meal with my granddaughter, and we’re both full” (Collins-Lauber, 2009, p. B3). Here we see that even extreme examples of deprivation were lauded and idealized, if not normalized, for WLS recipients. Another article that featured the WLS journey of two sisters also exemplified model patient behavior:

Supper at the Melnyk home is meager—one heaping tablespoon of potatoes, a bit of meat, a few pieces of cooked carrot. In total, no more than a cup. Helen and Marian Melnyk accept the small portions as part of the life-changing journey they embarked on together 18 months ago. (Ruttan, 2005a, p. A1)

In addition to diet, the rhetoric of hard work, control, sacrifice, and deprivation was evident and normalized in the area of physical activity. The ideal patient was positioned as relishing the opportunity to challenge herself physically, demonstrating commitment and dedication to weight loss and maintenance practices via physical activity.

An excerpt retrieved from another human interest story that focused on one woman’s successful WLS journey demonstrated this attitude:

Farner, who has lost approximately 40 per cent of her body weight since having her laparoscopic sleeve gastrectomy . . . has stuck with the plan, eating no more than 1.5 cups of food at any meal. . . . She swims every morning except Sunday, then meets Williams [her trainer] twice a week for hard-core cardio, resistance and weight training, pulling and pushing sleds filled with weights to the 44-yard line. . . . Farner is a model patient. (Sinnema, 2010b, p. A1)

Ultimately, ideal patients were positioned as embodying the neoliberal work of the continued body project and healthism (see Crawford, 2006), using everyday behaviors that involved self-surveillance techniques and particular lifestyle practices.

The failed citizen

The fat body, in its very corporeality, reveals failed citizenship, whereby citizenship is understood as being tied to neoliberal normative practices of self-discipline and restraint (Elliott, 2007; Markula, 2008; Petersen & Lupton, 1996). Among the other moral and social reasons, individuals accessing WLS, even those who behaved as ideal patients, were constructed as bad citizens because of the expensive procedure they required to control their transgressions. We found that the authors of most of the articles positioned individuals accessing surgery or with morbid obesity as failed citizens (n = 13). Most frequently, failed citizenship was constructed through morbidly obese individuals’ lack of neoliberal values, such as self-control, autonomy, and responsibility, displayed by their visibly fat bodies (n = 8). Posing a financial burden to the system (n = 6) and irresponsibly engaging in medical tourism (n = 2) were other ways that the authors of the articles positioned individuals accessing WLS as failed citizens. In addition, this subject position reinforced the obese stereotype and the othering of obese individuals within both the biomedical and benevolent government discourses.

The expense of the procedure, the cost to taxpayers, and the “burden on the system” were made apparent throughout the texts (six authors referred directly to the financial burden morbidly obese individuals or the expense of WLS put on the system). The quote from Collins-Lauber’s article concerning university funding illustrates this point: “$35 million in funding that the university has received for obesity research will put more resources into solving a problem that places a huge burden on the health-care system” (2009, p. B3). The author of another article also exemplified notions concerning the failed citizen, arguing that individuals needed to take responsibility for their health to avoid such failures:

If we care about what direction health care is taking in this country and province, should we not first look in the mirror and realize how we contribute to the health-care burden by not taking care of our own bodies? (Milanovich, 2005, p. A19)

The medical tourist: The embodiment of the nonideal patient and failed citizen

Although the medical tourist was discussed in only two of the articles, the subject position was one of significance that warrants mention, as it provides a contrasting and undesirable alternative to the ideal patient. In this sense, the medical tourist can be viewed as a rhetorical device used to reinforce the qualities required to be the ideal patient. Pafford (2009) defined medical tourism as patients traveling abroad for affordable health care. Authors offered the medical tourist subject position as the antithesis of the ideal patient—a position to be avoided at all costs—reinforcing ideal patient notions. The contrast between the medical tourist and the ideal patient ensured that readers understood there was only one correct, morally responsible position from which to access WLS.

In the articles, anyone who traveled abroad for WLS or even crossed provincial borders, perhaps to a private clinic elsewhere in the country, was automatically labeled a medical tourist. Medical tourists were depicted as thoughtless and irresponsible, the epitome of failed citizens, reinforcing the discourses of benevolent government and neoliberal ideologies concerning healthism. Medical tourists did not perform the “correct” neoliberal work of exercising control over their weight and weight loss, nor did they prove worthy of accessing government-funded clinics (that is, they did not enact the ideal patient subject position), as shown in this story about a woman who went to Mexico for WLS:

Janine said she headed to Mexico on a bit of a whim: She was feeling depressed before Christmas, concerned about the extra pounds that would come from holiday chocolate and treats . . . many [patients] return with dangerous complications that cost the Alberta health system thousands of dollars. . . . Money needed for [medical tourists] takes away money budgeted for others, the surgeons say. (Sinnema, 2010a, p. A1)

Furthermore, authors positioned medical tourists as individuals to be scorned because they skipped the queue, pushing aside ideal patients and ultimately costing taxpayers additional funds. This position was outlined in one of the articles written from the perspective of a surgeon from the Weight Wise clinic:

The system is stressed. . . . We’ve got our own patients to deal with. How do we deal with patients who go elsewhere? The problem is, when they go to Mexico, we don’t have any idea what they did in the operating room. (Sinnema, 2010a, p. A1)

In this article, the reader was also discouraged from considering why a person would travel for WLS, with the author implying that the reasons for doing so are selfish, silly (e.g., New Year’s resolution), or thoughtless. It is worth noting that wait times for WLS in Canada are 5 years on average, which is the longest wait for any surgically treated condition in the country (Christou & Efthimiou, 2009).

It was apparent that the authors relied on the creation of personal risk and anxiety throughout the articles, and these functioned to discourage readers from considering medical tourism—or from sympathizing with anyone who did. In one article, entitled “Foreign obesity surgery poses major health risk, doctors warn” (Sinnema, 2010a, p. A1), the author clearly drew on risk notions to discourage medical tourism. Another drew on the implicit rhetoric of the ideal patient, noting that surgeons cannot (and will not) help medical tourists when their WLS fails: “If the patient had the surgery outside of Canada, most surgeons won’t even take the chance due to liability purposes. Unfortunately, these are the surgeries that often fail” (Capital Health, 2009b, para. 7).

The expert: Benevolent father and gatekeeper of WLS

Within the biomedical and benevolent government discourses concerning WLS, the subject position of the expert created a particular space for the medical researcher, government official, or physician to garner power and control. The expert subject position functioned to construct and uphold the biomedical discourse, offering power and authority only to those with institutionally recognized credentials. The expert, in contrast to the ideal patient or medical tourist, was the owner of knowledge, distinct from those who were not. The expert was created and reinforced through the use of official titles and listings of qualifications and degrees. For example, when referring to one of the physicians at the Weight Wise clinic, the author of one article wrote, “He is also an Assistant Professor with the Faculty of Medicine and Dentistry at the University of Alberta. He recently completed his fellowship in Minimally Invasive/Bariatric Surgery at the Baylor College of Medicine in Houston” (Capital Health, 2009a, para. 5).

It was clear that one of the primary functions of the expert was to enforce guidelines and appropriate practices, ensuring that only the most deserving, ideal patients accessed surgery. In this way, the expert was also the gatekeeper of surgery, with the author of one article noting, “In Alberta, when patients qualify for bariatric surgery, they go through a rigorous preparation regime. . . . Most surgeons require patients to demonstrate a change in lifestyle and eating habits before the operation” (Sinnema, 2010a, p. A1). In turn, the expert-as-gatekeeper reinforced the ideal patient subject position by quite literally acting as judge and jury to ensure that patients adhered to the ideal patient rhetoric.

Moreover, paternalistic gestures served to engender and endear, creating a benevolent, father-like caricature of the expert subject position. Physicians were described as devoted and even loving, as demonstrated in one article highlighting a physician’s work: “Dr. Shahzeer Karmali began work in July and will devote almost all his time to weight-loss surgery for obese patients. . . . ‘I love bariatric patients,’ said Karmali” (Sinnema, 2008, p. B3). The father image was also evoked in the presentation of the physician taking a tough-love approach. His patient, a woman who had undergone WLS, was quoted as saying, “‘Dr. Davey is very strict. . . .You have to follow his rules, but he’s doing what is right for you” (Ruttan, 2005a, p. A1).