Episode 2: The “Ethical Dilemma” of Fat Fertility
Episode Summary
On this episode of Fat and Fertile, I describe the ethical dilemma many fat folks face when they start out on their fertility journey
We explore how the belief that it's dangerous for us to get pregnant impacts our daily life and we dive into the research around the ethics of getting pregnant in a bigger body
What to Expect from the Podcast: This episode explores the ethical dilemmas surrounding fat people's access to fertility care. Nicola unpacks common self-limiting beliefs that fat individuals may hold about getting pregnant, challenges the validity of BMI as a health metric, and critiques the discriminatory practices in healthcare that deny fat people the right to fertility treatment. Nicola also shares evidence and insights from research studies debunking the myths surrounding fatness and fertility, while emphasising the importance of self-advocacy and bodily autonomy in healthcare.
Highlights:
Common internalised beliefs about fatness and pregnancy (e.g., it’s dangerous or irresponsible to get pregnant in a bigger body) and how these beliefs stem from societal stigma and misinformation rather than facts.
History and flaws of BMI as a health measure and the systemic use of BMI to deny fertility care, especially in public healthcare systems like the NHS.
Research evidence debunking the validity of excluding fat individuals from fertility treatments based on BMI.
Weight Stigma in Healthcare and the impact of delayed or denied medical care due to anti-fat bias.
Highlighting that the so-called ethical dilemma is rooted in societal biases rather than genuine medical risks and the importance of bodily autonomy in decision-making about fertility care.
Links and Resources
Nicola’s book, Fat and Fertile
More info on the Fat and Fertile Alliance, Nicola’s community for folks looking for extra support on their fertility journey
Get Involved
Nicola would love to hear from you! If this episode resonates, share your story, ask a question, or leave a review.
Support the Podcast
If you’re enjoying Fat and Fertile, please share this episode on social or leave a review! Every share helps make this info more accessible to everyone who needs it.
Explore More with Nicola
Support My Work: Buy me a coffee on Ko-Fi to help keep my podcast and free resources accessible.
Follow Me on Instagram: Join me here for fat-positive fertility tips, updates, and encouragement.
Free Resources for Fat Folks: Access a hub of tools designed to support your fat-positive fertility journey, including guides, checklists, research summaries, and my popular Can I Get Pregnant in a Bigger Body? workshop.
👉 Explore all these resources here and take your first step toward parenthood without stigma or shame. I’m cheering you on every step of the way!
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Hey, my lovely Welcome to fat infertile the podcast. I'm Nicola salmon, fat positive fertility coach and author of The look fat and fertile. I'm obsessed with helping folks navigate getting pregnant in an anti fat world. On this podcast, we'll explore the complexities that fat folks face when you want to grow your family. If you want to support this podcast, I would love for you to share it on social media or leave me a review on your podcast app. And if you're looking for fertility support without a side of shame, and I would love to chat with you about how we can work together. Check out the link in the show notes for more information. Are you ready? Let's dive in.
Hey, loves, we're back again for another episode of flat and fertile, and today, we're going to be covering a super important topic called the ethical dilemma. Now I just want to say a quick thank you to everybody who subscribed who listened to last week's episode. It blew me away, how many people shared it and liked it and sent me messages. So thank you again for supporting this work,
this topic, the ethical dilemma, is so so important, because it impacts someone's journey into getting pregnant in so many different ways. The first way is
a belief that you might hold around getting pregnant in a bigger body. And then once we've explored that, we're going to look into the ethical dilemma that doctors and fertility clinics will often mention when they try to justify denying care and treatment to fat folks. So let's start with this belief that you might have around being a fat person who wants to get pregnant.
You might be thinking thoughts like it's wrong for me to get pregnant at my current size, or it's irresponsible for me to try and get pregnant in a bigger body,
or that it's dangerous for you and baby to try and get pregnant at your size, or that you'll already be a bad parent if you try to get pregnant. Now,
so many people have shared that the experience these kinds of thoughts every single day,
and it's really difficult to navigate those thoughts and to navigate getting pregnant in a bigger body when you believe that ultimately, it could be dangerous or irresponsible to get pregnant. So where do these thoughts come from? It's really important to clarify that these are thoughts and they are absolutely not facts. These thoughts that you have whilst they come from other areas where they've come from, other sources. They're not based on facts. They're based on other people's opinions about fat people
and all these thoughts might mean that you postpone trying to get pregnant until you've lost weight. It might mean that you actively avoid getting pregnant, even though you know that you want to start growing your family right now, and it might mean that you seek to terminate a wanted pregnancy for fear of consequences of continuing it. I
just really want to say that if any of those things apply to you, it is not your fault. Those actions are totally understandable, because we live in a world that tells us that fat people shouldn't get pregnant
if your actions are
not lining up with the fact that you want to get pregnant in your body, it's just your brain and your body protecting you from a perceived risk. And it makes total sense, because if you believe that it's dangerous for you to get pregnant, then whether consciously or unconsciously, you're going to avoid taking actions that are going to lead you to making it more likely that you're going to get pregnant.
So let's dig down into where these beliefs and thoughts come from. We aren't born believing that fat people shouldn't get pregnant. We aren't born thinking that fat is bad, that fat is unhealthy, that fat people are irresponsible if they get pregnant. None of these things we are born with. It's something that, over time, over years, that we conditioned to believe because of the culture that we live in. So we live in a world where thin is deemed the kind of socially acceptable thing for bodies to be.
And if you are any way outside of that thin ideal, and your body is deemed less worthy, and that doesn't only apply to fertility treatment, that applies to all forms of healthcare. I know folks who have been denied cardiovascular surgeries, gallbladder removal, so many different types of health care and treatment that are going to support their health based on their BMI.
And if you don't know much about BMI, BMI stands for body mass index, and it is a measure that
basically takes your height and your weight and calculates this number, and this number is used to often deny folks fertility support and fertility treatment within clinics. So in the UK, we have a system called the National Health Service, and if you want to access treatment there, there is a BMI limit. So BMI cut off of a completely arbitrary number, and they say that if you
if your BMI is above this number, then you can't access fertility care. Now, this BMI isn't based on any studies that show that folks over this particular BMI have issues or problems. BMI is actually a measure that was created by an astronomer and was based on a population of white, Western European men. And they looked at this population health and described this idea that folks who are in this higher category have higher incidences of ill health. And this was done a long time ago. It was based on this small subset of people, and has been proven time and time again that this number has no correlation with other health markers, such as blood pressure, blood glucose levels, other you know, things that we can now measure and use to get a snapshot of someone's health, and it is just a snapshot, because our bodies change and
improve and help themselves in so many different ways over time. So BMI has been completely debunked in so many ways, yet we are using it as a measure to decide who is able to access care and treatment and who isn't
okay. Getting back to the ethical dilemma.
The beliefs that we have and that we hold around being in a bigger body are really based on this foundational belief that fat is bad and that all fat people are unhealthy. But we know that this idea is outdated. It's racist and is not based on any robust science. It also takes into account this idea that it's really easy for someone to lose weight and that we can actually modify our weight in some way. But every single study that's looked at any form of intentional weight loss has found that
most of the participants, so the figure usually quoted as 95% of folks who engage in intentional weight loss will lose weight in the short term, but then over two to five years will often go on To regain that weight.
So the idea that we can change our bodies in any way is really
not rooted in science, and unfortunately, our understanding of the body and science is only as good as the people who are doing it. We all live in this soup of diet, culture of thin is good and fat is bad, where we're told that thin is right, fat is wrong, that fat people can never be healthy, which is why the people who are researching these topics, who are doing research into fatness and into health, and especially around fertility and pregnancy, they already start with this foundational belief that they will find something wrong. Every single study nearly that I read around fertility and pregnancy starts with this paragraph that kind of sets the scene for the research that says, you know, we know that fat people are unhealthy, and we know that there's an increased risk of this and this. So they're already stating at the beginning of each article their biases and the lens at which they see the world and they see health, um.
We're going to dive into kind of the perceived risks around pregnancy and fertility later in the season, but it's safe to say that the research is not black and white. It's not the case that all the evidence shows that BMI increases with the risk of complications.
Actually, what we found is that there's around a third of the data that shows conclusively
that there is a correlation. So as one rises, the other rises, and then a third shows that there's possibly a link, but it's not statistically significant, which means that you can't draw a conclusion from it, and about a third shows that there's no, no kind of correlation at all. There's no relationship between them,
and there's been no bio biological mechanism found to explain these proposed mis risks. We haven't found like
a process within the body that shows that when this happens, this causes this to happen? That this causes this to happen? We don't have that biological mechanism mapped out, so it's really difficult to say that we know that BMI increases the risk of complications through pregnancy, because we don't have conclusive research, and we don't have biological processes with which we can see that risk through. The second point is that none of that research ever takes into account the lived experience of being a fat person and how our bodies, respect respond to the anti fat bias that we face from society and healthcare. If you want to do a bit more research into this, it's called weight stigma. So it's this idea that being stigmatized based on the size of our body negatively impacts our health, and how that happens is because of the stress that we face living in a bigger body, not only internally from our own thoughts and beliefs that we hold around that, but also access to health care. Being able to get tests and treatments in a timely manner from doctors is makes it really difficult to be able to get that we care we need, and if we have a delay in that, say, for example, if your doctor says, Oh, the problem is, just wait, you need to come back in six months time. That leads to a delay in our treatment and leads to a, you know, a longer time between when we went to see our doctor and being finally diagnosed with what's actually going on. And that delay increases the likelihood of something else going wrong, of it being caught later, of there being more symptoms, of it being more serious. So being a fat person and experiencing weight stigma within healthcare has a very real impact, both in terms of the stress that we experience having to navigate those situations, and the delay that we often get accessing treatments and tests.
And finally, we should be able to make a decision about our body. It's our body, and we should be able to get the to make the choice around what happens to it. You get to decide what happens to your body, you get to weigh up the risks versus the benefits and make a decision about whether that benefit is worth the risk involved. A doctor should be there to offer their knowledge and their clinical experience. They're not there to make that decision for you. I know that doesn't always happen, and our healthcare often isn't framed in that way, but ultimately, the doctors and the healthcare providers require your consent. I just want you to recognize that having these conversations isn't always easy, as much as it is is technically right that you get to decide. In reality, it doesn't always work that way. Doctors are used to having a power over their patients, and we as patients have been conditioned to do as we are told. We have to consider our safety in those situations, especially for folks who are more marginalized, it might not feel safe to question your doctor, and that doesn't mean that you don't deserve the same level of healthcare. It's a shitty situation, but your safety must come first. So whenever you are navigating those conversations with healthcare providers, please remember that you are the most important thing, and whilst it's really important that you get your needs met in terms of access to healthcare, it's really important that you stay safe and don't put yourself in a position that feels unsafe. So what can we do?
Obviously, it's important that we get access to that healthcare, and we're going to discuss advocacy later on in the season. I.
But I would love to pose a couple of questions for you right now, if it's helpful, spend a little bit of time pausing the audio and just jotting down what comes up in your mind when I ask these questions. Have a little think about what you would do, what it means to you, and ultimately,
how it can impact what you're going through right now.
Okay,
so here are the questions that I'd like to ask you.
What if you believed that it was safe for you to get pregnant,
what would you do differently?
What if you believe that you were worthy of choosing when you grew your family, just like folks in smaller bodies, choose?
What would be different in your life if you allowed yourself to believe that getting pregnant was a possibility to you without having to diet and lose weight.
Have a think about these questions, and if you'd love to share, I'd love to know what comes up for you. You're welcome to email me or send me a message on Instagram at Fat positive fertility. I'd love to know what came up as you were thinking about those questions.
Okay, so let's shift gears a little bit and think about the ethical dilemma that fertility clinics and doctors use when they want to deny folks care based on their BMI. It's based on similar assumptions around fat equals unhealthy. But there's also two other components sneaking in here. The first is money for publicly funded services such as the NHS in the UK. People in charge of spending often need to decide where the money goes, and fat people are a socially acceptable way to reduce access to treatment.
Denying fat people access to health care is acceptable in our country, and that is abhorrent, that is violent, that is unjust,
but it's what happens, and it impacts about a third of people who want to access treatment in the UK,
the second component that often sneaks in is efficacy, or how effective treatments are. For private companies, they'll often use their success rates as a marketing strategy to attract more clients. There's a perception that fat folks have less success with fertility treatment, and we're going to dig into that later in the season, but it is a perception
so many clinics will cherry pick the clients that they work with and decide that they don't want to offer treatment to Fat folks.
Again, this is totally unethical, totally immoral to not offer treatment and to support to a huge group of people, and if this was any other kind of marginalization or kind of illness that people were experiencing.
Side note, I'm not comparing being fat with an illness, but for the medical industry that does see fatness as an illness, they would not do that with anything else. So why? We know why it's acceptable, but why? Why do they deem it acceptable to do to fat folks?
So there's a few great research papers out there that explore the ethics around denying fertility care to fat folks, and if you're interested in the studies, if you want to know more about the research, you can download the fully referenced research summary for free on my website, and I'll share the link in the show notes, but I want to share a few pieces with you now, just to really give you a flavor of what what Some of the really good researchers out there are saying? So in 2010 a researcher called Pandy and their colleagues wrote a debate piece for a journal called the Human Reproduction looking at the arguments for denying access to fertility treatment based on BMI, and they concluded that all the arguments used for excluding women based on their BMI have a poor quality of evidence to back them up.
Rebecca Brown of Oxford University wrote a really great paper in 2019 entitled irresponsibly infertile, obesity, efficiency and exclusion from treatment. Now, brown goes into great detail to look at the possible justifications for denying people with a higher BMI fertility treatment, and came up with a conclusion each time that it doesn't make sense to deny folks care based on their body size.
And the final words that I'm going to leave you with today on the podcast come from a debate piece by an author called coning, and it's entitled it.
Is not justified to reject fertility treatment based on obesity, and they say when discussing risks for the woman, but I'd like to say just folks in general, because it's more than just women who experience fertility issues, they highlight there are no additional risks for women. When undergoing IVF, they found higher risks associated with pregnancy complications. But again, we're going to talk about that later in the season, and then they go on to argue that although the risk is higher, it does not mean that it is irresponsible to take that risk, and that a competent and well informed person, in principle, has the right to their own deliberation when considering risk taken for themselves.
So I hope that this
brief outline of this so called ethical dilemma has been helpful, regardless of what the research papers say, what the healthcare professionals say, I want you to know that you are absolutely worthy of being able to choose when you want to grow your family and to be able to access all the care and support that you need in order to grow it. It's not an ethical dilemma. Fat people have the right to access health care support and non judgment based help regardless of their size.
Thank you so much for joining me today on fat and fertile. I'm currently welcoming folks to work together, one to one with me, either weekly over 12 weeks, or there's a one off consultation. These coaching sessions are great for folks who want guidance on how to navigate getting pregnant as a fat person, need support in advocating for themselves around fertility, and want someone on their side who absolutely believes in their body's ability to get pregnant. Check out the link in the show notes for more information and to book a free consult. Call with me see you next time you.
Get Involved: Nicola would love to hear from you! If this episode resonates, share your story, ask a question, or leave a review. You can also join the Fat and Fertile Alliance - a friendly space to connect with others on similar paths.
Support the Podcast: If you’re enjoying Fat and Fertile, please share this episode on social or leave a review! Every share helps make this info more accessible to everyone who needs it.
Apologies for any typos - transcribed byhttps://otter.ai - it can make mistakes! If you need clarification on anything - please get in touch!