I use to believe as many people do that an obese woman is over-weight because she eats too much. It was simple thinking and reflected my own ignorance as well as my inability to look deeper. Michael Myers MD does research on eating disorders and sexuality and he estimates that 40 percent of obese females have experienced sexual abuse. I work in a weight loss clinic and I too have seen this trend. Obesity protects a person from their sexuality since (in Western cultures) obesity is frowned upon and not thought of as attractive. How did we miss this? Why didn't more of us in the health profession notice it?

Much of ignorance has to do with our own taboos around the issues of incest and sexual abuse. We don't want to ask the patients about it because we don't want to offend them. We also don't ask because we have no idea what to say when they begin to cry and tell us their history of abuse.

The connection between sexual abuse and developing a weight problem has to do with the emotions of guilt, shame, self-punishment, self-comfort, and protection. The body image of a sexually abused woman (or man) is forever distorted. Sexual abuse violates boundaries and, therefore, what may be feelings of fatigue or hunger get confused. The patient no longer understands what they feel and they begin to comfort with food as a way of not feeling. Many of these patients try to starve themselves as way of maintaining control after being sexually violated. They try to control whatever they can so they won't feel vulnerable and so food becomes one of the few things they can control.

Reports from bariatric clinics show that 20 to 40% of patients seeking weight loss surgery have histories of sexual abuse. A study in 2001 for patients with binge eating disorder found that out of 145 patients being treated for binging, 83% reported some sort of abuse in their past (59% were emotionally abused, 36% reported sexual abuse, 69% reported emotional neglect and 49%reported physical neglect).

Suggesting to an obese woman that she should go on a diet or begin an exercise program is analogous to telling a three day a week jogger to run the Boston Marathon. It is overwhelming, discouraging and missing the point. The jogger has to be motivated and be confident that they could actually complete a marathon and, more importantly, that it would be worthwhile. If you have been abused and are obese you feel so bad about yourself, why would you want to diet or exercise? What would be the point if you thought yourself a failure so many times in the past? We have to begin to see this problem in a much different light. Some of it is the environment, some of it is genetics, but those things can be modified if the person has not been traumatized with abuse. If we miss this important aspect of obesity then no matter what kind of surgery or treatment we provide, the patient will not be successful.

Suggestions for healing past sexual trauma:

1. Get a therapist on your team who deals with abuse issues. Make sure that as a patient you trust this person and can rely on this person to be on your team.

2. Get at the bottom of your obesity issues (preferably before weight loss surgery). One good way to begin this is to write down every "tape" in your head. Try to remember who said it and in what situation you heard that tape. When do you repeat it now to yourself?

3. You need to get the experience out of your head and onto paper and then verbalize it to a trained therapist. This will help you look at it as an adult and will help your therapist guide you with letting go of the past.

4. Learn ways to calm yourself other than food. Support groups are good at helping patients feel connected with each other and also helps patients understand they are not alone in their suffering. A support group also offers "new skills" in dealing with stress that patients learn vicariously from each other's life experiences.

5. Learn how to mediate, pray and breathe. Nothing calms the body as much as deep breathing. This is an integral aspect of healing from abuse.

Our culture doesn't understand the depth of obesity. We find it easier to judge or label than to seek and understand. The next time you see an obese woman instead of judging her as lazy you may want to step back and question your own need to put her in a category. If she is forced to fit in a category, will we feel better about our self—and, if so, then why?

MJo