Radical Psychology
Volume Eight, Issue 1

Women under/in control?

Embodying eating after gastric banding

Samantha Murray [*]

As a woman living in the West, I know I am not alone in experiencing my embodiment as eliciting contradictory and multiple responses. As a feminist, I am committed to size diversity and to staging ongoing challenges to the regimes of bodily discipline that are so powerfully sedimented in our culture, enforced through weight loss and body maintenance. And yet, I am aware that all women, at times, feel ambivalent and conflicted about their bodies in a culture that prizes slenderness as central to, and requisite for, normative feminine bodily aesthetics. This is especially the case in a context where it is increasingly difficult, if not impossible, to separate medical constructions of the ‘healthy’ female body from the cultural standards of the attractive one (see Murray in Sullivan and Murray (eds.), 2009). Given the cultural expectations about femininity and appearance, fat women are often represented as inherently unfeminine, excessive and out of control, with a pathological relationship with food and eating. Troublingly, fat women are commonly positioned in the dominant popular imagination as irresponsible, out of control and as moral failure in a social context where ‘healthy eating’ and bodily maintenance has become an outer expression of one’s propriety and personal ethics. Having lived my childhood, adolescence and most of my adult life as a fat woman, I have been the subject of body prejudice and the widespread denigration of fat people -- a form of discrimination that still seems to be socially acceptable. While embracing the aims of the fat liberation movement and the varied forms of committed fat political activism that seeks to end discrimination against fat people and to encourage a celebration of size diversity, I also often struggled with feelings of ambivalence about my embodiment, resulting in a seemingly endless circuit of dieting, and later, with persistent lethargy, menstrual pain and other health problems.

Seeking medical help as a fat woman is a daunting, and sometimes traumatic, undertaking. While I believe that fat people generally are subject to widespread social and institutional prejudice and discrimination, I would argue that because of the long history of women being valued within the dominant heterosexual matrix based on their visible adherence to normative feminine aesthetics, the imperative for slenderness affects women in specific ways. I do not wish to suggest that fat men do not experience discrimination and conflict over their embodiment, however, for the purposes of this paper, it is women’s lived experience of fat embodiment, and the ways in which control comes to bear on this embodiment, that will be my focus. Many fat people (particularly, fat women) have a troubled relationship with the medical establishment, and often avoid seeing doctors because of the expectation of another lecture about the importance of weight loss. In just about every medical consultation I had, the issue of my overweight was broached by my doctor as, at best, a contributing factor, and at worst, the cause of whatever complaint I was seeking help for, be it a common cold, back pain or broken bones. Yet, as my health was worsening, I reluctantly went to see a doctor, who ordered a range of blood tests. These tests revealed severe insulin resistance, polycystic ovarian syndrome (PCOS), and hormone imbalances that effectively meant my body was storing fat. A variety of medications and a controlled diet plan were recommended.

I was defensive in the face of the diagnosis, as I felt my alleged ‘obesity co-morbidities’ were a legitimate means of compelling me to lose weight, as they were imbued with the seemingly inarguable authority of medicine. I remain unconvinced of the easy conflation of obesity with a long list of associated health problems such as diabetes, heart disease and hypertension (Must et. al., 1999), and yet, it appeared as though my diagnosis made me a convenient statistic. Worse still, after twelve months of medication and the requisite diet plan, tests revealed my situation had not changed, and it was recommended I have a laparoscopic gastric band implanted. I was personally and politically furious at this suggestion, especially as many fat activists assert that weight loss surgeries (WLS) constitute little more than violent “stomach amputations” in order to eradicate fatness (Wann, 2005). I felt my politics would be compromised by having the gastric band surgery, and would co-extensively confirm the oversimplified belief that weight loss was the key to ‘health.’ Despite this, my pain and lethargy was persistent and real.

After considerable angst, I reluctantly agreed to have the surgery in late 2005.

This paper offers a critical inquiry into the lived experience of eating and modes of control around food for post-operative bariatric surgery patients, with a particular emphasis on women implanted with a laparoscopic gastric band. I will be drawing critically on my own lived experiences as a post-operative bariatric surgery patient, and the daily negotiations and adjustments required in one's approach to food and eating with a gastric band in situ. In thinking through the changes in lived embodiment post-bariatric surgery, I am most interested in examining the centrality of individual 'control' in discourses about 'healthy eating' and dietary regimes in public health directives and popular attitudes about the treatment of obesity, and how this control is differently experienced, exercised and embodied (particularly by women) before bariatric surgery, and after.

Gendered Eating

A fat woman is always under medical and cultural scrutiny, and never more so than when she eats. The fat woman’s relationship with food is though to be defined by gluttony, addiction, indulgence and a lack of control - these popular attitudes are disturbingly internalized by fat women who often feel self-conscious about eating in public precisely because of the kinds of assumptions made about her relationship with food. As Susan Bordo suggests: “Ultimately, the body . . . is seen as demonstrating correct or incorrect attitudes towards the demands of normalization itself” (1993, p. 203). With food discursively separated into ‘good’ and ‘bad’ foods, our choices are understood to be representative of ‘correct’ or ‘incorrect’ approaches to bodily maintenance. If one sees a fat woman eating, for example, a generous wedge of cheesecake, dominant perceptions and responses can be laden with a number of historically and culturally specific assumptions and allegations:

“How disgusting!”

“How could she do it, does she not see how she is making herself even fatter?”

“That’s how she got like that in the first place!”

“She doesn’t really need to eat that.”

In her study, ‘Eating Out: The experience of eating in public for the overweight woman’ Dawn  Zdrodowski (1999) looks at the way fat women self-police their eating in public, and the ways they are policed by others. She interviews a number of fat women regarding this issue -- some salient responses are below:

Rose: I always choose healthy meals with plenty of veg . . . it depends on if people can see me when I am eating as to whether I have a sweet.

Ella: I don’t mind having fattening food such as pastry but I couldn’t be seen to be eating cake or fried foods such as chips.

Val: I have vegetarian meals because they look healthier . . . I’d rather have steak or chicken, etc. but often they come with chips and I feel as if everyone is looking at me (Zrdodowski, 1996, p. 661).

I have, at various times in my life, had the same sort of comments leveled at me if I chose to eat something not deemed ‘suitable’ to my size. However, my question is this: would we ask the same question if we saw a woman whose body was visibly and culturally coded as normatively ‘slender’ eating the same slice of cheesecake? We might note her indulgence, perhaps even share a conspiratorial smile with her in guilty pleasure, but I would suggest that we would not judge her consumption of the cheesecake in the same way as we did the fat woman. We have come to generally associate a slender frame with a ‘healthy lifestyle’, and this cheesecake (for the ‘slender’ woman) is more likely to be perceived merely a deserved reward for such daily constraint and a rigorous regime.

But I want to return to the way in which negative assumptions about fat women and food have been sedimented in the popular imaginary. Even if one were to witness a fat woman eating an apple, the response would still be about the negotiation of a pathological relationship -- that between food and fatness. She must be trying another diet, trying to lose weight -- but what might she eat when in private? Is she just another ‘failed dieter’? In this way, the fat woman’s relationship with food is always already undergirded by a dual anxiety about excessive bodies versus normative feminine appearance, and ‘health’ -- which has become more of a moral question than a clinical marker. Given this, fat women’s eating practices are dominantly suspected, and read, as being out of control, and therefore, pathological. So the question is this: can a fat woman eat anything without being seen as addicted to food? Can a fat woman be regarded as not being out of control around food? Can a fat woman simply be hungry? While her food intake may be modest even by ‘healthy’ standards, the fact that she is eating at all becomes a reinforcement of the perception of the fat body’s constant indulgence of its (allegedly) excessive desires (Murray, 2008).

In What’s Wrong with Addiction? (2002), Helen Keane compellingly interrogates the conflation of obesity and compulsive overeating, asserting that:

Those who remain thin despite eating much more than others are more likely to be considered lucky than viewed as suffering from an eating disorder. And because they would not experience the intense conflict between appetite and the desire to lose weight which characterises the overweight overeater, they escape the feeling of being out of control which defines compulsion. Put simply, it is only people who are trying to restrain their eating who experience it as compulsive. (2002, p. 15, my emphasis).

In short, fat women are always already policed by their cultural context, as well as policing themselves in and through their internalisation of negative assumptions about fat flesh. Having tried numerous diets from puberty onwards, I always experienced not only my relationship with food, but also the perception of my eating by others as factors simultaneously in constant need of my control, while being out of my control. I did not regard myself as a ‘compulsive overeater’ -- if anything, my memories of food and eating are overshadowed by an ever-present imperative of restraint. In a culture that defines success in and through normative gendered body aesthetics, all women are socialized to have a complex relationship with food and desire, particularly evident in commercial advertising (Bordo, 1993). Further, I acknowledge that some women, regardless of body size, may have a particularly difficult emotional relationship with food and appetite (Thompson, 1994; Chernin, 1994). However, I would suggest that the oft-cited medico-cultural conflation of fatness with compulsive overeating is disturbing and problematically universalizing: indeed, where fat women are often discursively positioned as being food ‘addicts’, I would suggest that, ironically, often the site of compulsion is a constant self-regulation and policing of one’s own eating.

Curing Compulsions? Bariatric Surgeries

In the context of the current moral panic of over the ‘obesity epidemic’, Western aesthetic objections to fat flesh have been simultaneously veiled and legitimized in and through the medicalisation of fatness via the disease category of ‘obesity’. While the World Health Organisation has recognized and listed obesity as a disease in the International Classification of Diseases since 1948 (James, 2008), debate over the status of obesity as a disease has persisted (Allison et. al., 2008). Problematically, in medical discourses about obesity, what is tacitly inferred is that ‘fatness’ can and should be recognized in the absence of cultural context or specificity as a singular intelligible category: however, fatness is “continually constituted and (re)constituted along a continuum of relativity that is governed by a series of gendered, classed and raced imperatives for normative bodily being” (Murray, 2008, p. 3).

Despite decades of acute Western cultural anxieties about fat flesh and the co-requisite establishment of a diet culture promoting a myriad of eating plans, weight loss organisations, and a slender body aesthetic, it was only in 1995 that the WHO declared obesity to be a “global epidemic” (WHO Report: 2000). Since this time, numbers of people undergoing various bariatric surgery procedures has steadily and significantly increased. The increased turn to bariatric procedures has garnered considerable public debate, suggesting such surgeries simply pose an ‘easy way out’ or a ‘quick fix’. Thus, it would seem that even as obesity has officially been designated as a disease, the popular construction of fatness as self-inflicted and the co-extensive expectation that it is the responsibility of the individual to resolve through the necessary hard work and sacrifice of dieting and exercise persists. Discursively, losing weight is still perceived as a task that should be undertaken by those deemed fat, and that must necessarily be defined by individual restraint, deprivation and will-power. Diets, by definition, involve careful regulation of one’s food consumption and a commitment to regular exercise -- given this, diets are imagined as requiring hardship as part of the ultimately ‘worthwhile’ outcome of good ‘health’ and bodily normalisation (Jutel, 2005). Competing discourses, informed by an understanding of fatness as a personal failing, position bariatric surgery either as a valid option for those who have engaged in numerous diets without success, or as radical procedures designed to achieve a result that should be attained through individual dedication, personal fortitude and hard work.

In spite of these convictions, a quick Google search for ‘bariatric surgery’ reveals a plethora of centres and surgeons offering procedures to those seeking a ‘solution’ to their weight, demonstrating its growing popularity and its establishment as a key treatment protocol for obesity. There is clinical research that documents the capacity for bariatric surgery to ameliorate co-morbidities associated with obesity, and even totally resolve conditions such as Type II diabetes (Ballantyne, 2003), prompting some medical literature to almost evangelically advocate bariatric surgery as a key treatment protocol for the ‘morbidly obese’. Oliver explains that:

In the 1950s, a bariatric surgeon named Howard Payne, who was looking to expand his practice, coined the term “morbid obesity” in reference to people with a BMI of 40 or more (a term that is widely used today). This special designation of a subclass of obese people allowed him to justify bariatric surgery when most doctors viewed it as a radical and elective intervention. (Oliver, 2006, p. 624).

Following Oliver, in fat activist circles and in some quarters of the healthcare profession, ethical criticisms of bariatric surgical procedures have been voiced. One of the key reasons for this is the relative dearth of longitudinal clinical studies to follow-up with patients who undergo bariatric surgeries, as well as the documented risks and complications involved with some of the associated procedures, and their post-operative management. One of the key size-acceptance organisations, the National Association to Advance Fat Acceptance (NAAFA) in the United States has established a firm position on the practice of bariatric surgery, and has issued a policy document stating they “condemn gastrointestinal surgery for weight loss under any circumstances... the psychosocial suffering that fat people face is more appropriately relieved by social and political reform than by surgery” (NAAFA, 2009, p. 1). Some medical professionals have also raised questions about the long-term effects of bariatric surgery have also been raised within the medical establishment. In the Journal of the American Medical Association, Mitka writes:

Short-term outcomes are impressive -- patients undergoing bariatric surgery maintain more weight loss compared with diet and exercise. Comorbidities such as type 2 diabetes can be reversed. But long-term consequences remain uncertain. Issues such as whether weight loss is maintained and the long-term effects of altering nutrient absorption remain unresolved (2003, p. 1762).

Mitka raises these concerns in response to what he suggests is an unequal relationship between the significant increase in bariatric surgery patients, despite the lack of long-term analysis of the effects of the surgery. Despite this, bariatric surgeries are now widely practised and regularly recommended for those deemed to be ‘morbidly obese’, even though these procedures are generally proposed as a ‘last resort’ option for people who have made concerted efforts to diet in the past without success. In fact, demonstrating that one has tried numerous weight loss strategies in the past is one of the key selection criteria patients are screened for in order to be an eligible candidate for the surgery. Other criteria include having a Body Mass Index (BMI) generally greater than 40, and suffering from one or more obesity-related co-morbidities (such as Type II diabetes, sleep apnoea, heart disease, etc.).

Bariatric surgery involves a range of varied procedures, including the major intestinal resectioning involved with gastric bypass surgery, most popular in North America, while in Australia, the most popular bariatric surgery is the implantation of an adjustable laparoscopic gastric band (Buchwald and Williams, 2004), a theoretically reversible procedure (though removal of the band is not generally encouraged unless significant complications arise). The gastric band (of which there are now a number of types) encircles the top section of the stomach, creating a small upper pouch, and larger lower pouch. The upper pouch is generally the size of a walnut, designed to limit the amount of food that can be ingested at one time to between 15 and 20 mls at a time, and to slow the motion of food through the stomach to encourage patients to feel fuller for longer. On its inner surface, the gastric band has an adjustable balloon that can be inflated with saline to augment a patient’s restriction, or withdrawn to increase the size of the stoma (that is, the passage between the upper stomach pouch and the lower section of the stomach) to permit greater food intake (for example, during pregnancy). The band is subject to ongoing adjustments post-operatively, performed via local anaesthetic, where the band’s port (most often stitched onto the abdominal muscles) is located with an x-ray, and saline injected into it with a cannula needle.

All bariatric procedures involve some form of food restriction, in order to drastically restrict the amount of food one can consume, thereby reducing the calories absorbed by the body. The result is rapid and dramatic weight loss. Unsurprisingly, in relying on techniques to enforce restriction, bariatric surgery operates from the dominant (problematic) assumption that all ‘obese’ patients are compulsive overeaters. As Rosik (2005) claims, “Binge eating disorder (BED) is probably the most studied psychiatric condition among the potential patient population . . . BED appears to be highly prevalent among those who seek bariatric surgery” (2005, p. 677). Indeed numerous studies have been published that examine the rates of Binge Eating Disorder (BED) in patients seeking, or having undergone, bariatric surgical procedures, thereby increasing the pathologisation of ‘obese’ subjects by assigning many profound psychological disturbances, and reinforcing the assumption that fat people are simply food ‘addicts’. It is therefore expected that instituting a system of enforced control in patients through bariatric surgical procedures addresses a psychological disorder, as well as a physiological one.

Enforcing Control

In general, patients are restricted to fluids only for two weeks immediately following the operation, and a further two weeks limited to pureed foods in order not to compromise the position of the newly implanted band. In the first two weeks following the surgery, I found it difficult to cope with the ingestion of little more than half a glass of water over a twenty-minute period without feeling overfull -- to try and drink anything faster would result in incredible pressure in my chest. Like many others who have undergone bariatric surgeries, I was panicked, wondering why I had agreed to have such a thing done to me.

After the initial four-week adjustment phase, patients are permitted to begin eating soft foods in small amounts. Surgeons often recommend patients make changes such as eating from smaller plates, and using teaspoons in order to ‘train’ themselves to eat more slowly, and to give the impression of enjoying a full meal. It is necessary to space out drinking and eating throughout the day: drinking with meals can flush food through the band too quickly, thus reducing the sensation of fullness and expanding the small upper stomach pouch.

Ogden, Clementi and Aylwin (2006) suggest that eating post-surgery becomes a simple response to physiological hunger that is satisfied with a minimum of food. It is thus suggested that through the institution of the enforced control of the gastric band, the careful self-regulation around food familiar to most obese patients is made obsolete. However, in the same way as the ‘diet’, I would suggest that the lived experience of having a gastric band in situ requires constant monitoring -- by doctors and by the patient -- involving careful and rigorous attention that makes food the focus of one’s daily activities. Eating plans are still necessary in order for patients to ensure they consume enough nutrients daily, as malabsorption is often a problem for patients. Additionally, events like social dinners can be difficult, as conversation may divert attention away from the mouthful one is chewing: if all food is not chewed to a smooth paste, it can become stuck above the stomach stoma, creating intense discomfort and pain, often resulting in the need to vomit. In 2006, Ogden, Clementi and Aylwin interviewed fifteen patients who had undergone bariatric surgery (14 were female and eight had undergone gastric banding). Some responses from the study participants note the difficulty of negotiating life with a band, particularly negotiating internal difficulties that are not apparent to others during social situations such as eating in public: “You’d be sick all the time . . . where could I be sick? How could I be sick quietly? I developed how to be sick, you’d flush the chain and be sick at the same time” (Ellen) (2006, p. 283).

Patients require frequent band ‘adjustments’ (known as ‘fills’) every one to two months to ensure ongoing weight loss. As the band is tightened, the stomach stoma reduces in diameter, making the range of foods one can eat increasingly limited. Foods such as red meat, white/brown bread, cooked rice, many raw vegetables and some fruits are often extremely difficult to ingest, as they cannot pass through the stoma created by the gastric band. Given this, if food is too hard, too doughy, or too fibrous, patients can avoid eating what might be regarded traditionally as ‘good’ foods in order to circumvent the intense pain that accompanies a blockage, and often results in regurgitation. What then happens, despite the fact that most patients have an extensive understanding of good nutrition gained through years of dieting, foods that are coded as ‘bad’ (with high energy density) such as custard, ice cream and chocolate are resorted to as they pass more easily through the band. For example, another respondent in the 2006 study by Ogden et. al. notes:

I actually love fruit and I used to eat a lot of fruit before but I can’t eat fruit. I can’t eat vegetables now . . . now I find that fattier foods I can actually eat better . . . (Sonia) (2006, p. 284).

Eating high calorie foods is then perceived as ‘non-compliance’ with the band, and by extension, a failure by patients -- often termed “sweet eaters” (Burgmer et. al., 2005, p. 685) - who are (allegedly) returning to ‘bad habits’ by consuming sweet or fatty foods. While bariatric patients typically experience a ‘honeymoon period’ of about six months where weight loss occurs quickly and without the return of significant hunger, after this time, patients can begin to struggle with the band and even regain weight. Alexander cautions bariatric patients: “You will appear like everyone else on the outside, but you are not. Don’t ever lose sight of that fact, or you will be in danger of slipping back into your old habits” (Alexander, 2006, p. 117). Given this, the negotiation of the band returns responsibility for the disease of obesity to the individual. As Ogden  asserts, the gastric band “is constructed not as a resolution in itself, but as a first step, or ‘tool’: a construction which leaves the work of weight loss with the individual, not the surgery.” (2006, p. 124)

Patients who undergo bariatric surgery have usually been obese for a considerable length of time, and have undertaken a series of diet programs that necessitate careful measurement of portion sizes and monitoring their daily calorie intake. While many diet plans promise a ‘freedom’ from focusing on food, the reality is that, while dieting, food becomes the centre of one’s life, where constant self-regulation, planning and awareness is crucial. As I noted earlier, with the help of Helen Keane, eating is experienced as a compulsive activity precisely because of the expectation of restraint from those who are instructed they are fat. Given this, a surgery that offers relief from the effort and scrutiny involved in dieting via the insertion of a device that institutes control forcibly, and at an unconscious, physiological level, seems a viable solution. As Ogden et. al. suggest, “ . . . by handing over control to their stomach rather than relying upon their own will-power, patients regain a sense of control over what they eat.” (2006, p. 271). Again, what is evident here is the problematic presumption that fat people are fat because they are necessarily compulsive overeaters, who lack the ability to exercise self-control around food. In short, as I suggested above, bariatric surgery is constructed here as a psychological intervention as much as a physiological one. In reducing the capacity of the stomach, Ogden et. al. argue that the food choices open to patients are greatly reduced, and the authors suggest that this enforced removal of choice that “ . . . may help a person to re-establish their sense of self-control.” (2006, p. 291) One can’t help but see the discursive gendering of eating behaviours here, via the reliance on the presumption of fatness as signifying uncontrolled desires -- a presumption that has historically been linked to women as beings who are fleshy, out of control and emotional, as opposed to the rational composed imagining of masculinity. Given this, one can see the way in which fat men are often ‘feminised’: they are often regarded as ‘soft’, too emotional. In short, fat men are seen to embody the worst traits associated with femininity.

The ‘Appearance’ of Control: Conclusions

Sharing dinner with friends I hadn’t seen since prior to my surgery, I found myself showered in compliments about my more normatively feminine appearance. And yet, as we were gathered around the table, I attempted to smile despite the distress at having food caught painfully in my chest. I had to find excuses to excuse myself repeatedly to escape to the bathroom in order to hide the reality of the situation: I would say “My stomach’s been a bit upset -- I must have eaten something bad.” During times when I did not having a problem keeping food down, my small portions were hardly noticed by my company: indeed, if they did notice, they might remark that I was eating lightly as part of my ‘diet’, being unaware of my surgery. As Throsby claims, for the bariatric patient, “the surgically induced inability to eat becomes a parody of ‘dieting like a normal person’ -- an act of passing which is achieved through the mobilization of the normatively feminine practice of dieting.” (2008, p. 127). In this way, not only did my embodiment become more visibly normative, but my eating practices were regarded as normatively feminine as well. Women are expected to exercise control around food: to fully satisfy one’s appetite with a hearty portion is often read as decidedly unfeminine. Women, most particularly, are discursively positioned as more likely to ‘comfort’ eat, or as to treat food as a reward, a solace. In this way, women who are fat are regarded as letting these gendered eating practices run completely out of control. While bariatric surgery is promoted often as a means of freeing oneself from the cycle of dieting and ‘failure’, and promises a ‘release’ from food as the focus of one’s life, I am suggesting the surgery merely resituates food and eating as the central aspect of one’s existence, and demands the ongoing physiological and psychic exercise of control, thereby disturbingly reaffirming fat bodies as fundamentally out of control.

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Biographical Note:

Samantha Murray is a lecturer in Cultural Studies in the Department of Media, Music & Cultural Studies at Macquarie University. She is the author of The ‘Fat’ Female Body (Palgrave Macmillan, 2008), and the forthcoming Fat Panic and Disciplined Embodiment: ‘Health’ and Bodily Aesthetics in the Management of Obesity (Palgrave Macmillan, 2011). Sam is also co-editor (with Nikki Sullivan) of Somatechnics: Queering the Technologisation of Bodies (Ashgate: 2009), and has published numerous articles and chapters on embodiment and the discursive constructions of normalcy and pathology.