Here goes:
Bariatric surgery, commonly known as weight-loss surgery, is increasingly being used as a treatment for what is termed ‘morbid obesity’ (a Body Mass Index (BMI) over 40 or 35 with co-morbidities). Although both the term ‘morbid obesity’ and the BMI system has been the source of much practical and genealogical criticism, they remain in common usage within the various discourses that surround the surgery. The surgery itself refers to a suite of interventions that radically and permanently reduce calorie intake through restricting the size of the stomach or resectioning and bypassing parts of the digestive system and accessory organs. What was once considered a last resort has become a staple treatment option, indeed some now consider surgical intervention to be the only viable long-term ‘solution’ to obesity. Driven by moral panic over the supposed obesity epidemic affecting our world, the upsurge in bariatric surgery is surrounded by conflicted and conflicting discourses regarding access and entitlement to the surgery, power relations and the morality and deviance of the people accessing such dramatic, permanent and costly medical interventions. Samantha Murray (2009 p. 154) has described bariatric surgery as a somatechnology of gender, and it is with this in mind that the present essay will explore how discourses around bariatric surgery both differ for and interpellate and (re)create gendered, racialised and classed identities. Despite this, or perhaps because of it, there has been little analysis of these discourses and the effects of weight-loss surgery outside of the activist and academic communities, although the healthcare field does have some dissenting voices. As a result, this paper attempts such an analysis whilst acknowledging the lacuna of discursive knowledge that surrounds bariatric surgery.
One of the most prominent discourses around bariatric surgery is, unsurprisingly, a medico-scientific one. Within this discourse, obesity is framed as a disease with significant physiological, psychological and social impacts upon the obese person-cum-patient. The medicalisation of obesity follows the epistemological shifts of the 18th and 19th centuries posited by Foucault (1973) that privilege the medical gaze, placing doctors (specifically surgeons in this case) as the knowing, legitimate authority and subject. This is what Haraway deems the God-trick, (1991, p.193) the false assumption of scientific objectivity. Haraway argues that the only real objective understanding can come from a place of situated knowledges and partial perspectives. This argument paves the way for an acknowledgement of multiple and simultaneous perspectives and experiences of the same situation, an understanding taken up by Karen Throsby in a study of a bariatric clinic and surgery patients in the UK (2007; 2011).
Throsby (2011) borrows Mol’s concept of the body-multiple to explore the experiences of people seeking bariatric surgery, suggesting that the same person performs and experiences multiple versions of the same obesity. Patients at the clinic primarily performed a cultural version of obesity in which obesity is framed as a moral failing, responding to prompts in confessional language: “‘I know’ she [Janet, a surgical candidate] says quietly, ‘I’m so ashamed of myself’” (quoted from Throsby, 2011, p. 2). The consulting surgeon, ever the knowing subject, disregards such confessions, erasing the socio-cultural aspect of obesity in favour of a scientific, medical one. For the surgeon, obesity is a disease (albeit one with multiple known and unknown causes) to be treated. The individual is absolved of any blame or moral failing, it is simply a body that has malfunctioned in its environment and is in error. In judging the merit of the candidate to be a successful patient, discourses of access and entitlement are reduced to physiological and statistical principles. This framing of obesity and bariatric surgery is in stark contrast to both the marketing and recruitment strategies of weight-loss surgery clinics and the construction of the post-surgical patient/body.
The framing of obesity on the websites of bariatric clinics is similar to the way in which the Banting diet pamphlets of the English Victorian era interpellated overweight and obese bodies: an unruly one, causing much psychological distress to the sufferer in their daily social life (Huff, 2001). The Banting diet offers the correctly interpellated subject the same solution as weight-loss surgery does today: an effective bodily intervention that will curb their excesses and social deviance (Huff, 2001; Salant & Santry 2006; Throsby 2011). Paradoxically, medical sites of knowledge (the clinic, the surgeons and the websites studied by Salant and Santry) utilise these conflicting socio-cultural and medical discourses: “The websites of bariatric clinics interpellate their viewers as both “the unwilling passive victim of a brutal disease whose only viable solution is invasive surgery and the potential agent of one’s own failure to achieve substantial weight-loss, particularly in the absence of continual surveillance and expert guidance” (Salant & Santry 2006, p. 2453). This conflicting message is noted in the work of both Throsby (2011) and Murray (2009) as a power shift from passive victim of disease to perpetrator of weak-willed immoral failing, effectively placing the blame for post-surgical weight-gain or less than expected weight-loss onto the obese person.
In addition to a focus of the social and mental suffering that accompany messages of purely biological framings of the obesity as a disease, traditionally feminine traits and tropes are incorporated into both the experience of obesity being retold (passivity, responsibility for self-monitoring, focus on appearance) and life post-surgery (transformation into happy, healthy, attractive and normal individuals) (Murray 2009; Saland & Santry 2006; Throsby 2011). The creation of the gendered subject is furthered by the aesthetics and images used on the weight-loss clinics websites. Themes of rejuvenation and metamorphosis are common, images of butterflies and before and after shots (mainly of white women) accompany pictures of happy couples and love (Salant & Santry 2006, p. 2450). The surgery is discussed in terms of personal empowerment and taking back control; both the visual and rhetorical substance mirror that of beauty makeover television shows and ugly ducking stories that perpetuate gendered notions of beauty (Salant & Santry 2006, p. 2450, 2454). The overabundance of positive images of smiling, freshly empowered white women is unsurprising given Connell’s notion of emphasised femininity (inherently white) and Sullivan’s (2007) problematising of legitimated surgical interventions as a tool of white optics.
Sullivan picks up Haraway’s (1991) concept of vision as “always a questions of the power to see” (2011, p. 397) to argue that legislation on ‘female genital mutilation’ in Australia, as an ideological state apparatus (although it can function as a repressive apparatus), functions to legitimate certain (white, liberal) ways of seeing. The privileging of the white gaze is also a feature of Alan Han’s (2006) paper on racialised economies of queer male desire. Han uses the theories of other critical race and whiteness studies scholars to explore the ways in which whiteness is privileged, a possession, a form of cultural capital that racialises the other whilst making whiteness invisible. Medical and (neo)liberal ideologies and discourses around bariatric surgery and those seeking it ie fat/obese people can be seen to function in a similar fashion. As a tool of white optics and whiteness, these discourses mask the effects of class and race on bodies and lives that produce the fat body that is so abhorred. The structural and social inequalities and violences that so often contribute to the ‘problem’ of obesity become invisible and bariatric surgery functions as a somatechnology to create an appropriate, white, middle class subject.
The invisibility and privileging of whiteness is part of a broader neoliberal discourse within society, and has a particular impact of the creation and subjugation of racialised and classed identities and fat bodies that can be seen in a discursive analysis of bariatric surgery. Dana-ain Davis (2007) calls the racialisation inherent in neoliberalism ‘muted racism’, to refer to the way that discussion of race (always linked to class) is coded to appear colour-blind and merely a discussion of merit. Davis argues that the neoliberal ideology that claims to position all people as equal serves to reject particularity and identity; “racism is modified by perpetuating the belief that it is incoherent and is not a real feature of contemporary life” (p. 349). In Australia, as in the USA where Davis works, a large portion of the overweight/obese population are both poor and Indigenous (and African American in Davis’ case), with lower rates of education and higher rates of the co-morbidities associated with obesity. Racialised neoliberal discourses disrupt the knowledge of how health is informed and shaped by socio-economic inequalities that are particularly high for racialised groups. Thus, neoliberal discourses create a racialised bariatric patient that is exponentially more to blame for their obesity and less entitled to the surgery that is seen as more appropriate for ‘passive disease victims’.
Racialised neoliberal discourses also speak to deeper neoliberal and cultural discourses: the ever-present paranoia that hordes of undeserving layabouts are draining the health and welfare system. Examining this fear, Roberts and Mahtani (2010) map the way that neoliberal discourses create particular racialised subjects through the lens of human geography. In particular, the constitution of the good, appropriate citizen (opposed to the illegal immigrant and the welfare-queen; the white, middle class and healthy in relation to bariatrics) and their relationship with and contribution to society. This intertwines with the neoliberal obsession with individual responsibility and denigrates those who access the surgery, seeing them as taking an easy way out via an extravagant and costly method (Drew 2010). Throsby’s own work with weight-loss surgery patients shows this: the obese subject is aware of the condemnation directed towards them and the surgery, worrying about and defending both the origins of their fatness, attempts to lose weight and their own value as a statistically good candidate for surgical intervention (2007; 2011).
Obesity is frequently linked with notions of excess in both neoliberal and cultural discourses. Excess weight, excess consumption and excess skin all figure in Throsby’s (2011) analysis of the enactment of obesity in the context of the surgery clinic. The excess weight serves as a visual symbol of their ill-health, an excess weight that will still be there, albeit reduced, after the surgery. The fat body also symbolises and makes undeniable through vision the familiar association with uncontained appetites. Excess consumption belies a “moral incontinence” (p. 9) of the fat person, not just with bodily ramifications but public and global consequences. The fat failed citizen is blamed for the greedy consumption of public resources, snatching them out of the hands of more deserving folk (Drew 2010; Throsby 2007; Throsby 2011). Obesity surgery and its obese patients are implicated as an immoral excess.
The discussion of excesses of obesity and weight-loss surgery reflect more than a preoccupation with neoliberal ideals of equality and individual responsibility. They articulate a moral imperative towards the good health and productiveness mandated by Foucault’s disciplinary society (1979) and biopower (1976). The disciplinary society is marked by both constant self-surveillance and restraint and the docile body, amenable to shaping and utilisation. Biopower furthers this, requiring the body to act as a machine but is also concerned with the (re)productive capacity of the population. Both seek to create an effective, disciplined and pliable society. The fat body, as an unruly and excessive subject, is both a danger to economic productivity (through ill-health), social cohesion and population control (being outside normal parameters as well as fertility and parenting concerns). Those seeking bariatric surgery are framed as a danger to society, to themselves, and to their families that is draining public resources to remedy the situation. However, given that their post-surgical bodies will still be overweight (Throsby 2011), they are still subject to that framing. Further, the visual nature of their deviance compounds these effects and discourses.
The moral imperative of health is also driven by optics, by what is seen and unseen. The conflation of health with visibility and aesthetics has been investigated by Samantha Murray (2011). A recipient of weight-loss surgery herself, Murray uses personal narrative as well as theory and ethnography to recount the privileging of vision in the treatment and construction of people who have had bariatric surgery. Hidden behind rapid weight-loss, the bodily effects of bariatric surgery remain a secret. Malabsorption, diarrhea, vomiting, constant hunger and restraint manifest as a (closer to) normatively sized body engaged in dieting, as a culturally appropriate feminine attempt to lose weight (pp. 158-160). Well intentioned cries of “you’ve lost weight, you look so good/healthy/happy” reinforce the conflation of vision with health. Murray argues that medical and cultural discourses of health mask “an acute cultural anxiety about the ways in which the fat body disrupts privileged ideals about normative gendered bodies and aesthetic appearance” (p. 151).
However, it is important to remember that fat bodies, people and patients are never completely interpellated as the deviant subject or suffering subject (Huff 2001, p.57). The enactment of obesity is never singular, and the actors never simple representations. People seeking bariatric surgery are aware of the ways that they are viewed, of how discourse functions to mask the realities of their lives as well as the junction of knowledge and power. Both Throsby (2007) and Drew (2010) interviewed patients that negotiated and talked back to disempowering discourses, and whilst Haraway (1991) was right in cautioning us against innocent powers being the only representatives, more research needs to be done that incorporates them and respects their lived realities.
Bariatric surgery is a complex issue with multiple ideologies and discourses all intermingling to create an equally complex subject. Throsby considers obesity surgery an ‘uncertain cure’ (White 2009 cited in Throsby 2011), “one that, while having some success in relation to specific medically defined goals and practices, intersects with (and contributes to the enactment of) other obesities in ways that have to be negotiated, physically and socially, long after the end of the surgical treatment pathway” (p. 3). Conflicting medical discourses create both a diseased and excessive, gendered and racialised obesity. Neoliberal discourses compound the racialisation of the surgery candidate, bringing in issues of class and citizenship. Consumption of public services is deemed excessive and inappropriate for the morally failed obese person, indeed their body itself is an insult to the state and the family. Cultural discourses mirror these notions, relying on vision and aesthetics in the construction of the fat body, the gendered, raced and classed fat body. The somatechnologies of race, class and gender create the original Haraway cyborg, a hybrid of flesh and visceral bodily technologies, viewed only through the limits of vision and legitimated, knowing optics; “surgery changes more than a BMI” (Throsby 2011, p. 6).
References
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