The Fat Doctor Podcast

How a Positive Consultation Changed Everything For Me

• Dr Asher Larmie • Season 5 • Episode 18

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 Medical trauma is more than an abstract concept—it's a physical reality that impacts millions of people daily. In this episode, I share my transformative experience at a gender identity clinic, contrasting it with previous healthcare encounters that left me hypervigilant, tense, and bracing for judgment. 

I explore how our bodies physically store medical trauma—in our gut, our muscles, our posture, and even our skin—creating patterns that repeat with each new medical encounter. For fat people and those with other marginalized identities, this trauma compounds exponentially. 

This episode invites listeners to recognize medical trauma's physical manifestations while questioning a healthcare system that continues to perpetuate harm despite decades of evidence. 

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Hi, everyone and welcome to episode 18 of the Fat Doctor Podcast. I'm your host, Dr. Asher Larmie, and I'm going to tell you about my own experience of a good medical consultation that I had recently. I'm very excited to share that with you, and to highlight how bad my experience of doctors has been in the past, and why this was different. So today is all about my appointment at the gender identity clinic. That's right, folks. I finally had my appointment. I've been waiting for a few years.
I had a telephone triage appointment back in December and had my clinic appointment at the Chalmers Centre in Edinburgh last Tuesday. I'm wearing my Trans T-shirt today in solidarity with my trans siblings. It's a tough time at the moment, and it was really quite amazing that I had this experience in the midst of a political nightmare, where we're all arguing about who gets to go to what bathroom.
I'm not getting into that. But I'm going to talk to you about my experience at the gender Identity Clinic, and why it was so awesome. And then I'm going to talk about previous experiences and why they were not awesome, and compare the two. And then I'm going to talk a little bit about why I react the way that I react whenever I'm faced with a doctor. And all about how holding on to medical trauma impacts all of my healthcare consultations.
So that's what today's all about and content warning. I'm going to be talking about my own experiences. You might find them triggering. I apologize if you do, maybe you want to skip this one. If you're feeling a bit fragile or sensitive, maybe you want to check out the transcript first before you dive into it, or check out the chapters and just skip the bits that you find a bit triggering.
Let's talk about last Tuesday at the Chalmers Centre in Edinburgh. It's a lovely building, and it's very inclusive. You walk in there and immediately feel safe. All the toilets are gender inclusive, and there's nothing offensive on the walls. I went into reception. I was welcomed instantly. They very sensitively handled the BMI thing. Basically, the receptionist was really kind, she said, "Look, the clinicians here would like us to record your BMI and your blood pressure. There's a self-serve machine that you can use. If you want to do it, then I'll show you how. If you don't want to do it, then you can just go and take a seat in the waiting area."
That was great. It felt very much like either option was fine. There was no pressure. I just went, "Oh, I could do my blood pressure, but not my BMI." And she said, "Actually, you have to do them all together on this machine, so never mind, just go take a seat."
It was lovely. I didn't feel like I had to fight it. I didn't feel embarrassed or anything. She was really good about it. I was welcomed instantly, I felt very safe, I felt very respected. Throughout the entire appointment there was no judgment. There were no assumptions made. Everyone took the time to really clarify things, never assuming anything about me.
My doctor was great. She was really lovely. She put me at ease immediately. She really listened. She was actively listening, and she was typing. She was typing, as she explained, and as all doctors would agree with, we have to write up quite a large set of notes after we finish every consultation, and a lot gets said. If it happened in the past we can miss things, forget things, miss bits out, miss important information. We're expecting our memories to recall things which perhaps isn't safe. So actually, writing notes during the consultation is quite important and helpful.
We used to write handwritten notes. Everything's done electronically now. So there is a reason why doctors are typing—it's to remember stuff. But it's very simple to learn the art of communicating and actively listening whilst typing. She first of all said, "Look, I'm really sorry I need to type," and explained why. That's not a problem. But she was listening, and you could tell, because every so often she'd stop, she'd go "Right, so can you just explain what that means," or she would, you know, it was obvious that she was paying attention. She was able to recall the things that I said.
She didn't rush me. She didn't interrupt me once. She let me speak and followed along, which is what we call a patient-led consultation. When the patient is basically doing the talking, and you, as a doctor, are doing the listening, and then every so often asking important questions. But other than that, allowing the patient to lead the way.
She made sure that I was involved in all the decisions. And it was really quite incredible. We had a one-hour long consultation, which in of itself is amazing. How often do you get offered an hour with a doctor? But, she explained it was my initial assessment, and about a quarter of the way through she went, "Look, we have an option here. We could carry on with the initial assessment, or there are some things that have come up already which I could probably address in the here and now. So do you want to deal with that now, or do you want to carry on with the initial assessment? And then I'll bring you back to do the other thing. Which way do you want to go?"
That was amazing. No one has ever in my entire life, when I've been at a doctor, involved me in that decision-making process. The doctor made the decision, whereas in this case she was like, "Well, what's most important to you? What do you want to do now? What do you want to do later? I'm obviously going to have to bring you back. So what do you want to do? This is your consultation."
She explained things very clearly, even though she knew that I was a doctor. She pitched everything at the right level, and there wasn't any talking down to me, but there was also no making assumptions either. I wasn't left with any confusion. I was able to ask questions I wanted to ask. She took me really seriously, and actually recognized me as the expert in my own body. At no point did she dismiss what I said, or try to convince me that she knew more than I did. Quite the opposite. Everything I said was like, "Yep, totally understand. Yep, I understand. I agree," and very validating.
As I said, she recognized me as the expert of my own body, which was great and felt really good. After an hour, there were still loads more to do. But that's the case with these types of appointments. You can't just get it all done in an hour.
But it was really good. I left with a plan. There was no like, "I'll see you next time." There was a "This is what we need to do still, this is what I was thinking we could do next time. How would you like to do it? When would you like to do it? When's the best time? Would you prefer evening? Would you prefer daytime?" All these options. Not too many to overwhelm—enough options that I felt like I was in control. I felt like I had autonomy, I felt like I could say "Stop" or "No," or "I don't like that," or "I want to move on," and that would have been fine. She offered me that over and over again. She checked in with me. She was continually getting consent as well, which was really great.
It's a very rare skill that I've noticed when a doctor is just checking in. "Is it all right for me to ask about this? Is it okay if we talk about this? Or should we move on to something else?" She didn't assume, because I had consented to the consultation, that I had consented to every aspect of the consultation. And so if there were things that I didn't want to talk about, then she was like, "We can come back to this, or if it's too much we can move on."
It was really great. She was asking some very challenging questions, but gaining my consent like that was really quite unusual. I've never felt so in control of a doctor's appointment before, so empowered. I really felt like I was in charge.
I didn't bring up my BMI at all. I brought up my BMI when I was talking about surgery. I said, "Look, I know that there are certain types of surgery that are going to be really difficult for me. There are going to be certain types of surgery that I'll never be able to access. I've made my peace with that. I know that there are BMI limits." She didn't say anything. She was completely neutral. She was just letting me talk, and I found that really helpful as well.
And it was really different to my previous experiences. I'm trying to think back at all the appointments I've had with doctors in the past. Not every single one. They're not all bad, but it doesn't actually matter that they're not all bad, because enough of them have been really bad. I have felt completely judged, whether it was by a look. Sometimes it's just the general attitude—you can just tell. It's nonverbal communication. Seventy percent of communication is non-verbal.
So when you feel like you're being judged, chances are you're being judged. Now I know that when we're used to being judged, we will rush to assumption that we're being judged again. And so there might be a doctor that isn't judging us. But actually, that's not relevant at this point in time. I'm not talking about whether or not a doctor was judgmental or not. I felt judged.
They didn't do enough to ensure that I didn't feel judged, and I would argue that that's a responsibility of a doctor. It's not to just be like, "Well, I wasn't doing anything." No, you need to go out of your way to build what we call rapport with a patient, basically to let them know that they are safe. They are not judged. You need to be active about this—actively ensuring your patient knows that they're not judged.
If you meet a patient that is living with one or more marginalized identities, is experiencing oppression, has most likely experienced stigma and trauma in a medical consultation in the past, you've got to go out of your way to be like, "I'm not going to judge you. I'm going to prove to you that I'm not judging you." With the relaxed posture and the openness, and the listening, and all of that stuff and then not judging. And of course, if you are judging them internally, it's going to be obvious. No point in denying it.
I have always felt unsafe, and that's one thing I realize is that when I go to the doctor I feel very unsafe. It takes me back—triggers all of my childhood trauma. I am not safe. I am immediately like—danger. This is a threat, and there have been really horrible situations. I can remember when doctors were having conversations with me in public spaces like in waiting rooms, having conversations that other people could hear, lecturing me about weight loss in front of other people. Not only is that not respecting confidentiality, which is a central part of being a healthcare practitioner, but how unsafe is that? Or having conversations with me when I wasn't fully clothed, having conversations with me when I was being touched, when I was being examined, making comments that feels really threatening.
I can remember being in a breast clinic, for me as a fat trans person, one of the most unsafe environments you can imagine, and having to deal with the judgment where a doctor comes in, and you've got to imagine this—only a surgeon can get away with this—a surgeon, by the way, in a hospital that I worked at. So I was a colleague, but that doesn't matter. It doesn't matter, because it should be everyone. I had been breastfeeding at the time, so I had somewhat uneven breasts to start with, and I had been breastfeeding so the bigger one I hadn't fed out of, so that looked even bigger, and then the smaller one I had just fed out of, and so that looked even smaller. So I had this noticeable difference in the size of my breasts.
This doctor walks in with three medical students, stands in front of me whilst I am disrobed, top completely down, looks at me and goes, "Have your breasts always been that uneven? Look at that," and starts pointing. And I was like, "Are you kidding me?" My chest is exposed, and you can't just sit there in judgment and talk about it. You can ask the question. It's a very important, relevant question, because it could be a sign that something pathological was going on. But you don't do that while someone's sitting there disrobed. That's totally inappropriate. You don't talk to your colleagues. You don't teach your students like that. You do it correctly.
The fact that the surgeon thought he'd get away with that just says everything you need to know about the fact that doctors do not care whether they are a threat or not. It doesn't matter. Your safety is irrelevant. This is how we do it. Teaching is essential. Teaching is essential. I agree. I was a medical student once. I understand that, but there is a correct way to do it, and there is an unsafe way to do it, and most doctors are very unsafe.
How many times have I been on a ward round with doctors, and all we have is curtains, because this is the NHS. This is the UK. We don't have private hospital rooms. Everybody is in a bay, and there are curtains, but that's not stopping the noise. And there are all these doctors having very loud conversations. Why are you having a loud conversation for other people to hear? That is not safe. It's disgusting.
Many a time I felt massively disrespected by doctors, and I think that says a lot, really, because generally doctors respect other doctors, so if they're willing to openly disrespect me, I cannot imagine what those doctors are like with other patients. Having heard the things that people say in the back room, the way that people talk about immigrants and foreigners and people who are out of work and on benefits, I've heard them speak. I know what they're thinking.
So I'm not surprised that they're judging, and that they're disrespectful. But I have been disrespected many a time, as I'm sure you have. Doctors continually make assumptions about me. Either I'm doing something wrong, I'm not eating the right stuff, not exercising enough, I'm not doing what I can to control my blood sugar, I'm not, you know, it's all my fault, always my fault, obviously. Either I'm doing something wrong or I'm not doing something right. It's one or the other. "Oh, that's wrong. Oh, you should be doing this." It's always my fault. I'm always to blame.
And there's being dismissed as well. "Oh, that can't be it." It's very much the case with blood sugar. If you're diabetic, you can understand this. "Oh, your HbA1c has gone up. Why is that? What have you done?" "Nothing." "Well, what haven't you done?" "Well, I've been doing everything correctly." "Can't be the case. Your HbA1c has gone up." "Well, maybe it's because I've been really stressed lately, or I've been in pain." "No, that couldn't do it. That wouldn't do it." First of all, yes, it would. Absolutely it would. And second of all, why are you blaming me? It's completely unnecessary and harmful.
And not being listened to—having doctors typing, then there's this awkward silence whilst you're waiting for them to finish typing. And then they look up and they ask a question, a very closed question. And then "What was that? Oh, right? Yeah." Type type. Look back. Their primary focus is writing up the notes. Their primary focus is getting that done. And you are their secondary focus, which is nonsense.
I have been consulting for 20 years as a GP. Since 2009, I have been typing on my computer and consulting with patients, and I can guarantee you there was never an awkward silence, and if there was, I'd be like, "I'm really sorry I need to write this down. This is very important. I can't get this wrong," and I would apologize to my patient immediately. Otherwise I would be typing and listening, and it would leave loads of spelling mistakes, and half-finished sentences, or just do bullet points, whatever, and knowing that I'd have to come back to it and type it out correctly, and that would require extra time, which I didn't have, and it would mean that I'd be late for my next patient, or I'd have to eat into my lunch break, typing up my notes. And that wasn't pleasant. It wasn't fair. It wasn't right, but it was my job, and so I accepted it. Now the real issue is not having enough time with patients, but that's by the by.
And then there's that feeling that the doctor just knows—the paternalism in medicine. I remember going to medical school, and one of the first things was "Paternalism is a thing of the past. We don't do that anymore. We don't think we know best." Yeah, that's what you say. Your mouth is saying one thing, your words are saying one thing, and you are doing the opposite. You absolutely think you know best. All of my colleagues think they know best. I've never met a doctor who doesn't think they know better than their patients. Well, they don't.
They don't understand. They're not experts. We went to medical school. I had to suffer through an entire year of pathology and virology and microbiology, and I had to learn about the clotting cascade and tumor necrosis factor alpha. And I had to learn all this stuff. That makes me an expert? No, it doesn't. The irony is the more you learn, the less you know. You think you know everything, and then it just turns out you don't. And then, of course, you do all this textbook stuff in medical school, and then you go out into the big, wide world and you meet patients. You're like, "Nobody ever presents the way they said they're going to. I thought they were supposed to act like this, but they don't. I thought this was supposed to happen—oh, very rarely, or sometimes, or maybe? I thought this was the right blood test, and if this was positive, it means this. No? Well, most of the time, sometimes, depends. You have to put it in clinical context." So we don't know that much, and oftentimes the person who has been living with this condition for years knows way more than we do, having spent 5 minutes with them. But it's very difficult for our egos to handle.
And finally, I was thinking about how this consultation ended, and I did this awful thing that my patients do. "Oh by the way," right at the last minute, "there was one other thing actually, that's really important. I can't believe I didn't remember that." And I wrote down notes and everything. And I was like, "Oh, yeah, there's this other thing." She stopped. She listened. She acknowledged. She wasn't just like, "Get out. It's late." She was like, "Okay, yeah." And I wasn't dismissed at any point in time.
And I said to her as I was leaving, "I just want you to know that I'm going to leave this room, and then I'm going to process for a second, and then I'm going to cry tears of joy." And she said, "Oh, I thought you were going to say you were going to cry. Because if you're going to cry, stay, and we'll figure it out." And I was like, "No, no, tears of joy. Don't worry, I'm happy." And it was a really lovely moment, but there was no dismissal. It was like I was ready to leave, and I didn't feel myself itching to get out of the consultation room. I was quite happy to stay there and talk with this doctor, which says a lot, really.
We talked about trauma last week with Elle, which was really helpful. I've been working with Elle for a little while now on and off, and not just with Elle. I've been in therapy for many years, and I've also been learning a lot about trauma and the trauma response and why we feel the way that we feel when we're around doctors.
And I was thinking about it—what happens? If you're watching the video right now you can see me closing my eyes. What happens? How do I feel in my body? Because oftentimes that's the way that I connect. I connect the best by actually just stopping for a moment and thinking about what I feel when I'm sitting in that waiting room, when I walk into that consultation room, when I sit down with my doctors.
And I wrote a list, folks, because there's a lot. I feel hypervigilant. I am on edge. I am easily startled. I am looking for threats. I've been doing the ruminating and the looping and the rehearsing in my head for weeks. I am preparing myself, because the more I rehearse, the better the outcome will be. That's what I believe. Anyway, it's not true, but it's what I believe.
So I'm hypervigilant, or I'm the opposite. I'm just shut down. I'm numb. I'm just spaced out, staring at a blank wall, not really engaging with the world around me, and I often swing in between the two.
I find myself—I don't know about you—but I can't sit and read a book. I notice some people sit and read a book when they're in the waiting room. I'm just like, how can you concentrate on that right now? Don't get me wrong. I love reading. I could read, sitting down on a chair, book in one hand, drinking with another, happy days, but in a waiting room? No, I can't concentrate. I just keep reading the same line over and over.
If I pay attention I notice that I'm breathing quite fast and quite shallow, and you can actually hear it. It's almost like a whistle. I am very nasal, as you can probably tell. I have blocked sinuses, and I always have, and a deviated septum, and so I can hear it—my breathing becomes quite loud, quite shallow, and my chest can sometimes feel a bit tight, like I'm holding something in.
And there's an overwhelming urge to cry, scream, shout, run away! All sorts of emotions, but it's quite strong that desire, and I'm trying to push it down. Hold it in. Clench, clench, clench so my chest feels tight. I'm bracing, basically. I'm bracing, and I'm holding it in. So there's tension in my muscles, in my jaw, and my neck, shoulders are up by my ears. Sometimes my fists are clenched, and there's tension in my lower back, my hips. Sometimes I notice it. Sometimes it actually starts to hurt. But sometimes I'm just quite rigid. I am ready. Literally my body is getting ready for impact. It's getting ready for a fight or to run. I am in fight or flight mode because my body remembers all of the other previous trauma. It doesn't even matter what happens in this particular experience. I have had enough horribly traumatic experiences that leave my body in this state. And so it happens every time. It's a learned, it's an unconscious, learned response.
My gut—how many of us acknowledge and recognize the fact that our gut and our brain are very much connected. And I think that comes up a lot when we talk about food. And you know, "food is not fuel"—that's nonsense. Food and the digestive stomach system is very much connected to the brain and the parasympathetic and sympathetic nervous system. We store a lot of our trauma in our gut. Hello, IBS, welcome. Take a seat. Those of us who have a functional bowel issue where we get a nervous tummy or an anxious tummy, there's a really good reason for that. One of the things is, it's a trauma response, and that can really impact you in the long term.
It can impact everything, including your hunger, fullness cues, it can cause diarrhea, constipation, nausea, vomiting. I often feel a bit sick, but it could cause anything.
I also start scratching, and this is something that I didn't always recognize. I suffer from dry skin and eczema, so I will often pick. I'm a skin picker, which is quite a combination. I imagine the two are related. If you know about the scratch itch cycle—when you're stressed, that increases inflammation. When you're in the sympathetic fight or flight response that increases inflammation. But when you're in the parasympathetic rest and digest response, and when you're able to move in between the two very easily, that can actually calm inflammation. The vagus nerve, which is an important part of the parasympathetic nervous system, the rest and digest nervous system—that nerve is connected to the spleen, and can actually communicate with the spleen and be like "calm down, calm down on the inflammation front."
So inflammation can be up when you're constantly stressed, which is very common, and autoimmune conditions and flare ups can result. But also skin conditions which are more allergic in nature—that can also be linked to stress. Did you know your skin holds your trauma? Your gut holds your trauma, your muscles hold your trauma, your skin holds onto your trauma, and so you can become very sensitive to touch, to temperature, to any kind of sensory input, and you can find yourself itching. So sometimes I'm scratching, sometimes I'm itching, sometimes I'm getting flare ups.
I noticed that my posture changes when I'm in a consultation. And one of the things that I'm learning to do is intentionally change my posture, make it open, but also make it quite assertive. Shoulders back, chest out, tuck my pelvis in, eye contact. I am making a statement here. But naturally I just want to contract and withdraw, and put my head down and not communicate. And again, as a neurodivergent person, that's my natural state, anyway. But masking is almost essential.
And this is a little bit for me, and I think this is probably a lot for other people, that our pelvis and our hips as part of our body are connected to all sorts of things, to shame, to sexuality, to safety, to boundaries. And so it's quite common to carry a lot of your unresolved trauma in your hips and your back and your pelvis. So again, when you're feeling very activated, if you're sitting in the waiting room, you're with a doctor, it's not unusual to experience pain or experience symptoms in this region.
And all of these things are really important to notice. I'm beginning to recognize how my unresolved medical trauma is showing up in my day-to-day life, but especially when it comes to accessing healthcare—how it's impacting me in my physical body, how it impacts my emotions. My emotions are obviously just signals, messengers telling me to pay attention. And I'm paying attention in this moment to my thought patterns, my adaptive behavior, and my coping mechanisms. All of those things I'm beginning to become curious about.
I've talked to a lot of people who are just like "Medical trauma—like it's a thing," and perhaps even acknowledge that it's a thing. But then they're like "We don't really talk about it. We don't really talk about how do we cope with this." And even when I talk to psychologists and therapists, a lot of them say "Oh, that's a subspecialty. That's not my specialty."
So it's quite difficult to get support, isn't it? It's quite difficult to get support and learn to process this medical trauma that we are collectively experiencing. And if you are a fat person, if you're a fat person who holds additional marginalized identities especially, you are going to experience medical trauma on a regular basis. It's almost impossible for you not to have experienced it. And if you're a fat person who holds one or more other marginalized identities, especially, you have probably experienced other forms of trauma.
There's this sort of intersectionality to it all, especially if you had childhood trauma. So you experience childhood trauma, and then you experience trauma as a result of your oppressed identities, in my case, transphobia and obviously fatphobia, and also as a neurodivergent person, ableism too. You've got all of that that you're contending with in your everyday life. And then there are specific incidents that happen within the medical consultation that are almost inevitable because of the systems that are operating in our modern healthcare system. It's the systems, it's the structures. It's inevitable.
Because even as a doctor with the best will in the world, I recognized the harm that I was perpetrating on my patients. It's why I've walked away from medicine. It was impossible not to cause harm and practice medicine in my experience. And so medical trauma is kind of an inevitability. So people are being traumatized all the time. And where's the support? Where's the help?
Watch this space is all I can say. It's definitely something that I've been contending with a lot, and something that I will continue to talk about in the future. Obviously, as we mentioned in the last podcast, it is technically Mental Health Awareness Month, which kind of gives me the ick—kind of like Autism Awareness Month kind of gives me the ick, because there's all this toxic positivity and spiritual bypassing and all this nonsense, and also all these horrible stereotypes about autistic people and people with mental health problems.
But it is interesting that in Autism Awareness Month, the "Make America Healthy Again" group of fascists decided to talk about autism and then create an autism registry. I'm not surprised that happened. And I wouldn't be surprised if this month there's a real attack on our mental and emotional well-being. Because if you can keep people stressed, activated, sort of in a trauma state, then it's much easier to usurp them, to control them, to do your bidding and get away with it. So don't be surprised if it comes up, and I will try and resist that. I will try and fight back with my awesome podcast content.
Now let's move on to "Everything you've been told about weight loss is a lie." I just found an old study the other day, and I thought, "I really need to talk about this study." It was done in 1970. It's really quite offensive. And it's by Swanson and Dinello, and it says, "Follow up of patients starved for obesity." They didn't even care. They didn't mince their words—"starved." We starved them. That's what we did. We got permission from the Ethics Board to starve them.
And they basically took only 25 subjects, and they called them "super obese," which is kind of like "super fat," and a lot of people like the term super fat, so I'm comfortable with super fat. I'm going to call them super fat now. And so they took 25 subjects—not participants, subjects—and subjected them to a period of starvation. They just starved them in hospital for an average of 38 days. It was slightly different for each subject, and then followed them for varying lengths of time afterwards. They found that the patients who were followed up for under 2 years, 23% had gained back more than they had lost, and if they followed them up for more than 2 years, so the full amount, which was 50 months, about 4 years, 83% had regained more weight than they had lost.
That's evidence back in the 1970s. Not definitive evidence because there was hardly a landmark study. But we know this. We have plenty of evidence to support this. A lot of people who go on a diet, and especially if they "starve themselves," will end up not just regaining or restoring that weight, but ending up actually heavier.
And this was supported by science even back in the 1970s. You have to read the abstract. It's not funny at all. Actually it is funny, because it's very true. And I wonder how we got this in 1970, but we still haven't caught on to it yet. "The patients had marked difficulty dieting after hospital discharge. They were starved in the hospital. In the face of routine, family and work stresses, the maintenance of weight loss was complicated by the psychological problems which were more apparent in these subjects when they were thin, and by the great amount of energy which they had to devote to dieting, particularly when they faced the stresses of daily life outside the hospital. For most patients a return to obesity was more comfortable and tolerable than trying to fight with the problem in the presence of environmental demands."
So it's rather offensive, but also makes some really good points. Number one, it's all well and good when it's contained starvation—it's contained, we're going on a diet, we're going to starve ourselves, it's fine, but you can only do it for a certain amount of time. And then your body's just like "I'm not doing this anymore."
So then, of course, when they were discharged, there were "psychological problems"—in other words, poor mental health. When you're fat, super fat, your mental health is going to be affected. Why? Because of the trauma that you're experiencing on a regular basis, because of the isolation and disconnection from society. All human beings have a need to connect with other human beings and with their environment around them and with themselves, and of course, that is ruined by white supremacy and by weight stigma and fat phobia. So of course—psychological problems, not surprising.
Super fat people in the seventies, I doubt they were having a great time of life. And also "there was a great amount of energy which they had to devote to dieting." Yes, that is correct. It becomes your sole purpose in life, and guess what—there are other things competing for your energy, like a job, like a family, and forget your own needs. You're usually too busy meeting other people's needs. And when you are starving yourself, you don't have energy to meet your own needs, let alone anyone else's. But you still have a life. You still have responsibilities. You can't just be like "I'm just going to stay here in my room and starve myself." It doesn't work that way.
So yes, psychological problems—in other words, poor mental health, and it's requiring a lot of energy. And so they said, "a return to being fat was more comfortable and tolerable than trying to fight with their problem in the presence of environmental demands." In other words, it just isn't possible, which is why it doesn't happen.
I tell people all the time: Weight loss is unsustainable, and my critics will say, "Well, if they just tried harder, if they just kept at it for longer, if they didn't quit the gym, if they didn't stop calorie restriction." And I'm like, "Yes, okay, fine." But even if that were true, which of course, we understand that there are biological and physiological reasons why that's not possible, why it's not possible to maintain that energy deficit for long periods of time, how our bodies are simply not equipped to do it, and if we do, our kidneys will shut down, we'll go into heart failure and we'll die.
So it's not possible to maintain a calorie deficit, no matter how fat you are. People are like, "Oh, well, you've got energy stores." It doesn't work that way. Eating disorders are eating disorders. Starvation is starvation. The body is not equipped to deal with it. Even if those people were right, even if "I just tried harder," it's not possible. It's not possible. And as these very ignorant researchers from the 1970s pointed out, fighting against environmental demands, against stress, against trauma and trauma responses and against your own basic biology is too much to expect of anyone. Hence weight loss is unsustainable. It just is. You can blame us if you want. It doesn't matter, because it's still unsustainable.
And that's very relevant for today's "ask me anything" portion of the podcast because I got this email. And I said, "Look, friend, I'm going to talk about this on the podcast if that's okay." The email was very simple: "I told my friends that no one needs to lose weight. And she said, 'What, even people who weigh more than 600 pounds?' I had no answer. I don't believe that weight loss is the answer for anything, but I'm curious as to what you think about this."
And this comes up all the time, and I think I've mentioned this before, and I'll say it again. There's a reason people say 600 pounds, not 500, not 400, not 620. There's a reason people go for 600, and that's because of subliminal messaging and a stupid TV program. And if you're American, you know exactly what that TV program is. But it's infiltrated society to the point that we will reach for that number 600. Such a bizarre number! Why not 500? It's not even round. It's such a weird thing.
But "not even people who are 600 pounds?" It's a really interesting question, isn't it? And I think when it comes to the point where you are fat, your weight is impacting your quality of life. That's not to say that your weight is to blame for your quality of life. It's to say that society is set up in such a way that people over a certain size will be automatically rejected, pushed out to the fringes of society, unable to connect, unable to engage, unable to progress, unable to get a decent job and get a promotion, and it becomes harder and harder as you get fatter and fatter. And that's a society problem. It's not a personal individual problem.
But when you get to a certain stage where a lot of people who are 600 pounds will say, "Actually, life is quite hard. I'm really struggling." And so I get that. I want to say that I have the deepest understanding and compassion, and I think there are probably—I think that fat bodies are often holding on to trauma, and I think it would be, if we were going to have a really nuanced conversation and debate about this, if you were a person who weighed 600 pounds and wanted to have a conversation with me about it, I would be like, "Can we talk about trauma? Are we able to start to talk about it and try to release some of that trauma?"
So I wanted to put that out there. But the point I really want to make here is that weight loss is unsustainable, and that even this study from the 1970s shows that when you starve super fat people, after they stopped being starved they will regain the weight, and then they will end up heavier.
And chances are if you're 600 pounds, that's what's been happening to you for most of your life. You've been starving yourself, and then you have been restoring your weight and then gaining extra weight. And there are lots of reasons, lots of biological physiological reasons underpinning this.
So I guess my question is—here's the friend saying, a member of my community who's told their friend "No one needs to lose weight," and friend said "What, even really fat people?" And the point is, well, what's the other option?
Molly did this quite brilliantly a few episodes ago, when we were talking about neurodivergent people and struggles with food, especially children. And she was like, "Well, what's the other option? You're just going to force feed your kids?"
So that's what I want to ask. If you're 600 pounds, and you know that starving yourself is going to lead to weight loss, weight loss attempts are going to lead to weight restoration, in many cases weight gain in the long term, what is the option here? What's on offer?
And I find that even when it comes to dramatic weight loss attempts like weight loss surgery, and weight loss injections which I'm sure is what people say—"Oh, these people need to go have surgery and have injections"—I'm not saying yes or no, that's a personal decision, but we regain weight with those things, too.
We restore weight. It's inevitable. And if you're 600 pounds, even if you have bariatric surgery, you're getting down to 450 max. That's crazy amounts—you're not going to suddenly, magically, miraculously be thin. That doesn't happen. With injections, it's maximum 15%, I reckon, depending on the studies. 15% of 600—you work it out. Do the math.
So it's not going to make a person skinny. It's not going to make a person thin. It's going to make them weigh less, and then chances are they are going to slowly restore that weight, and eventually they will end up possibly even heavier than when they first started. So there is no option.
And I just think, what do we do? What a horrible situation to be in when you're a super fat person, and you're being talked about this way. "Well, you know, we shouldn't be telling these people to lose weight." Why? It's unsustainable. They're going to end up restoring it. I don't get it. Why would you tell somebody to do something you know isn't going to work, and might actually end up making them heavier in the long term? Not that I think that's bad per se. But you understand what I'm saying here—the logic of it. It's cruel. It's not right, and we've got to stop doing it.
We've got to find better ways of talking about this, and I'm not sure I know the answer. I'm sure I'll look back in a few years time, listen to this episode and go, "That didn't age well!" I'm sure there are better ways of having these conversations, and really I haven't spoken to enough people upwards of 500 pounds. I haven't had these conversations. We haven't had these dialogues. That's a me problem. And I'm just going to acknowledge that.
And of course I would support any decision that any fat person ever made about their weight. I am a hundred percent supportive. But I'm speaking to the people who just love to bring up the 600 pound fat person. And also, I'm very conscious of the fact that we love to attack small groups of people, the ones who are already on the fringes of society, just as we're doing at the moment with conversations about bathrooms.
I'm not sure which bathroom I'm legally supposed to use now, and I'm not so mad because I'm passing. But as a trans man in the UK who looks like a man and who passes as man, that's really hard right now, because you're not allowed to go into the men's toilet legally, and you're also not allowed to go into the women's toilet because you're going to get in trouble. So what do you do? You just don't pee, basically, because that's the way that life goes.
We are cruel to small groups of people. We just want to attack trans women—0.1% of the UK is a trans woman. But it's fun to attack small groups, and I think it's the same thing with really fat people. We, as fat people, make up a very large percentage of the population. They keep quoting the fact that a third of the population is "obese." But there is a spectrum, and there are people like myself who are small fats, who find it's not easy, but it's not that hard. And so we have to be far more mindful of the people who are more pushed out, forced out to the fringes of society.
All right, I'm going to stop there. Next week we're going to be talking about how we don't owe society a debt of health. We're going to be talking about the financial burden of being fat. And I might get a little bit angry. I'm not going to lie, but that's next week's episode. Thank you very much for paying attention and listening in. I'll see you next week.