Weight Loss Surgery: A Feminist Issue

Every so often I get totally immersed in a subject and try to read everything I can about it. My most recent subject of interest is weight loss surgery (WLS), which is becoming more popular each year in the US. About 80% of weight loss surgeries are performed on women.

There are many different weight loss surgeries available. Many people are aware of stomach stapling and lap banding procedures that reduce the size or capacity of the stomach (either temporarily or permanently). Fewer people are aware of the intestinal bypass portion of some weight loss surgeries. The small intestine, which is instrumental in absorbing nutrients (such as carbohydrates, fats, protein, vitamins, and minerals) is also altered in various weight loss surgeries. Surgeons can make the stomach contents of a patient empty into the small intestine further down the line than it normally would, the intent is to prevent the patient from absorbing as many nutrients as they would otherwise. Patients who have WLS that includes shortening or bypassing of the small intestine have to take regular supplements (and at a much higher dose than people who have not had WLS). Roux-en-y, the most common type of weight loss surgery, both makes the stomach smaller and shortens the small intestine.

The main claim behind the surgeries is that it improves the health of patients by causing weight loss. The claim seems to rest on the idea that drastic weight loss has health benefits that outweigh the cost- not a very well established claim, which I will return to later.

There are also claims that it can reverse diabetes in some patients, as well as other problems correlated with obesity. Being obese and having diabetes, for instance, can be seen as a reason for a patient to be approved for surgery. I found this troubling for reasons that the American Diabetes Association covers quite nicely:

Myth: If you are overweight or obese, you will eventually develop type 2 diabetes.

Fact: Being overweight is a risk factor for developing this disease, but other risk factors such as family history, ethnicity and age also play a role. Unfortunately, too many people disregard the other risk factors for diabetes and think that weight is the only risk factor for type 2 diabetes. Most overweight people never develop type 2 diabetes, and many people with type 2 diabetes are at a normal weight or only moderately overweight.

There is no real way to tell if an overweight person with diabetes is someone who would have the disease at an average weight. Diabetes can increase the rate of complications in any surgery, so there should be a damn good reason for subjecting a diabetic patient to it. There is also no real way to tell if the surgery will actually cause long term weight loss in any specific patient. It seems that most patients who get WLS are still obese after losing weight.

Researching WLS becomes troubling very quickly. Anyone who undertakes the task will repeatedly be told that there are no long-term studies documenting the health outcomes of the surgeries. It is hard to understand why, when it is easy to find stories from people who had their surgeries in the 1970's and 1980's. These are surgeries that permanently alter vital organs, and the surgeries are still being performed despite the lack of important information.

The studies that claim a benefit typically do not follow the patients for more than a year or two, despite the pitch for the surgery typically saying that there is a "honeymoon period" of massive weight loss for a few years, and then some weight will come back later. It seems as though it would be important to follow up on the patients after they stop losing. There are two reasons for some of the weight to return. First, the stomach expands over time and allows for more food (ideally). Second, the honeymoon phase is a period of forced starvation, where the body is forced to burn tissues other than fat to survive, and the muscle that gets eaten away during starvation returns eventually. Some patients find that they hold onto weight more stubbornly and gain weight on much less food after surgery, due to their bodies adjusting to long term starvation conditions. Patients often adhere to a starvation level diet for life in order to avoid weight gain.

Studies that talk about resolving diabetes or obesity via WLS rarely discuss if the patients developed other problems as a result of the surgery (trading one set of problems for another). It can be very misleading.

For instance- statistics about patients who lost weight and kept it off include people who vomit chronically, have severe nutrient deficiencies, or who die years later from problems related to the WLS. These women are considered success stories and could be included as patients who kept the weight off or got rid of diabetes or heart problems as a result of the surgery. The links provided are stories of people who are either dead or disabled from their complications; there are many more who have the same problems and did not keep the weight off (or lose it in the first place).

This may not be a problem within a society that doesn't stigmatize people for obesity, but ours does and it complicates the ethical problems associated with allowing WLS on such a scale. Weighty Secrets is full of stories of women who faked their way through their psych examinations or lied about their height in order to get surgery. Some women put weights in their pockets to qualify. The outrageous thing about it is that the lap band procedure has been approved for people who are barely obese. There are people who admit to having the surgery out of vanity or as an extension of their eating disorder, they are not being filtered out by the procedures in place.

The stigma put on fat people often makes them less likely to raise hell when their WLS fails or causes them severe problems. Doctors can insist that the patient is at fault rather than the surgery because information about a pattern of problems associated with WLS (like auto-immune disorders, neurological problems, hernias, anemia, osteoporosis, beriberi, etc) is not readily available to most patients. If a doctor tells a patient they are at fault, most are willing to believe them. A physician notes how post op patients who are less healthy, but more thin, will advertise the surgery to anyone who will listen:

Several of my patients have had bariatric surgery, two of them over thirty years ago when it was a rarity. Some of them sailed through splendidly and are living happily ever after as thin people. Some of them are not doing so plendidly, even though they had the same surgeons and the same procedure. One lady passes kidney stones every couple of weeks. Another regurgitates anything solid that she tries to eat and yet has only lost 20 pounds in six months. She says she makes up the calories in liquid. Another can not eat more than one slice of toast at a time without getting sick. Some have chronic diarrhea. Many have nutritional deficiencies. A couple have gained their weight back after 10 or 20 years. And yet, not one of them says they regret having the surgery, such is the praise they get from others for losing weight. If asked, every single one of them would call themselves healthier, but from my perspective their health is worse. They all require more monitoring and more interventions than they did before having the surgery.

I believe the problem is made worse by the patient demographics- the majority of patients are women who have been socially programmed to be polite and self sacrificing. It is hard to know how many stories of weight loss success turned out less than wonderfully over time, but were never updated online or in surgeon's offices.

Junk Food Science points out that there is a debate within the AMA about the ethics of performing the surgery. The idea of weight loss as a goal in and of itself is scientifically controversial. Obesity has only been correlated with health conditions, not identified as a sole cause of any condition. Lifestyle and genetics play a role in the conditions typically associated with obesity. There is also controversy over the danger associated with the surgery itself (the junk food science series is well documented and thorough). There is some difficulty in calculating the death toll because deaths related to WLS may be ruled as a different cause, depending on the patient's weight, though the official numbers show that it is a high-risk surgery when compared to procedures like hysterectomy or appendectomy. One telling detail is that there had to be a campaign on behalf of WLS companies/surgeons in order to get bariatric surgeries covered by insurance companies, who have very little reason to reject procedures that would actually prevent health problems in the majority of patients.

The surgery is certainly sold like a cosmetic procedure, with before and afters being used to attract potential patients. Free seminars are used to tell patients about the surgery, often implying that patients will die from death fat if they don't get surgery soon (which is pretty unlikely). Combining the fat-shaming beauty mandate with the fear mongering Obesity Epidemic language is a powerful mix of rhetoric, which appeals to many women who have accepted that fat bodies (including their own) are evidence of inferiority.

Other increased risks for post ops are suicide, alcoholism, and cross addictive behaviors. These things are not typically mentioned by surgeons trying to sell weight loss. Starving yourself has long been known to alter the mood and psychological health of humans.

Additionally, these surgeries require lots of follow up from medical professionals permanently. Blood tests are needed to check for malnourishment, supplements need to be calculated to fit those needs, complications need immediate medical intervention and may arise years after the surgery, etc. There is also some debate about if the surgically induced malabsorption affects the effectiveness of hormonal birth control pills . In the US women need a degree of economic privilege in order to get health insurance, so they may be dependent upon husbands or corporations which exploit them for life as a result of the one time decision to have WLS. Younger people are being encouraged to have the surgery, including some teenagers, who don't have the means as adults to monitor their post-surgery health.


This isn't to say that no one should have these surgeries, I am sure it is medically necessary and makes sense against other risks for a small number of patients. However, it is also clear that there are many women who have no medical reason to get the procedure and were allowed to anyway. Many of those women now have psychological or physical problems permanently, or are dead. Some have difficulty with pregnancies afterwards because of the strain of providing nutrients to the fetus. Physicians are supposed to prevent harm from coming to anyone, and I very much consider this harm. I am fairly sure that the reason women get this surgery so much more often than men is that the pressure to be thin impacts us much more. The harm brought to women from diet pills, eating disorders, cosmetic surgery, crippling contraptions (corseting, foot binding, high heeled shoes, etc) are mainstream feminist issues. I had difficulty finding any information about WLS from feminists, though fat activists have discussed the issue quite a bit through a feminist perspective. The deaths and pain of women who felt their perfectly healthy organs needed to be sliced up in the name of beauty are hidden too far from the view of feminists. Empowering women who had negative experiences with WLS to speak up and update any testimonials they gave for surgeons would be a great start in bringing this issue to the mainstream of feminist discourse. For many women WLS is a socially approved, surgically enforced eating disorder. Women have their bodies operated on instead of having their heads examined when they pay thousands for someone to physically force starvation on them. Not only that, but other people congratulate them for it.