Under A Magnifying Glass: My Experience with Sizeism

This essay was written in 2014 as a reflection on a traumatic experience I had as an undergraduate at Dartmouth College - specifically with their health clinic, Dick’s House. I haven’t publicly shared this writing until now, and I have largely left what I wrote as is, although my perspective on health has evolved over time. See the post-postscript at the end for my current views.

“I don’t understand.”

I gaped, tears trickling down my face. My hands trembled as I stared at the blood test results that I had received just minutes ago.

“Is this my fault?” I uttered, partly pondering aloud and partly asking the counselor sitting across from me. She offered a vague response that failed to clarify my current predicament. Incoherent, bewildered thoughts raced through my head; each moment passed too quickly to comprehend and yet so excruciatingly slowly. It was only in this dream-like state that I perceived my life—my plans and aspirations, my health and my future—falling apart, transformed into a nightmare in a matter of one morning.

This encounter was preceded by a follow-up visit with a physician’s assistant at my college’s student health clinic. That morning, I received an urgent phone call from the health clinic insisting that I come immediately to discuss the results of blood work that I had done a few days before per my request. I had been feeling fatigued and, due to my history of iron-deficiency anemia, wanted a blood test to determine if I needed to increase my iron supplement. Consequently, I was examined by a P.A. who ordered the blood work and who, accordingly, met with me to discuss the troubling results. This visit, much like my discussion with the college counselor, remains scarred in my memory. What I initially gathered from my follow-up with the P.A. was that my health was in danger. According to him, I was “hanging off a cliff,” and if I kept “traveling down this path” I could experience organ failure. I had no idea what “path” I was going down, but I knew that organ failure was definitely a bad sign, so I assumed that whatever was wrong with me must have been serious. He mentioned that treating my condition could be dangerous and may trigger heart failure, so it was vital that I enter a center that could monitor me and, essentially, ensure that I wouldn’t die. His words disturbed me greatly—not only did it appear that my health was in imminent danger, but I did not understand why it was in danger. I had come to the clinic due to mere fatigue, only to discover that I was on the verge of death.

Both the P.A. and counselor urged me to medically withdraw from the summer 2014 term at Dartmouth College, more fondly referred to as my “sophomore summer.” I balked at the thought of withdrawing but was presented with no other option: if I refused to voluntarily withdraw, I was told that I would be forced to withdraw. Anyway, confronted with the possibility of death, I recognized that my focus should turn to my health, lest I suffer organ failure and deteriorate even further. And with that—along with completing paperwork and scavenging across campus for signatures to satisfy the requirement for medical withdrawal—my summer term came to an unforeseen and unfortunate end, after just the second day of classes.

Only later did I start to realize the precise diagnosis that Dick’s House had determined; an email from the P.A., sent subsequent to my withdrawal, identified my illness as a “nutritional deficiency (also known as an eating disorder).” As I painfully recognized that my critical condition was purportedly the result of an eating disorder, I began to question my identity and sanity. Years before, as a sophomore in high school, I had been accused of having an eating disorder due to unexplained weight loss. However, this weight loss was a symptom of undiagnosed Celiac disease, which caused malabsorption; my diet was sufficient, but my small intestine was simply not absorbing the calories and nutrients that my body needed. After the trauma of this initial misdiagnosis, I had never imagined that such an error could repeat itself. The misdiagnosis made by Dick’s House was not simply a repetition of past trauma that had already been etched into my memory—it was even worse than my experience as a high school sophomore. Not only was I misdiagnosed, but I was forced to withdraw on the basis of this misdiagnosis. I was eschewed from the college, stigmatized as an individual with an “eating disorder” who needed to enter a facility where my every move could be watched.

It was astounding to think that the P.A. and health clinic team involved in my withdrawal could rush to such an erroneous conclusion based on insufficient and distorted evidence. Admittedly, I do have a low body weight; I have never been able to regain the 15-20 pounds lost during the onset of Celiac disease. I have tried drinking Ensures and have visited nutritionists, but my body struggles to gain weight. In addition, I know that I possess traits often found in individuals with eating disorders: I am a diligent, disciplined, self-critical perfectionist who puts forth massive effort in all endeavors. I would also venture to say that I have an obsessive-compulsive personality—I often worry and tend to perform all tasks with a compulsive, determined focus. Nevertheless, I do not have a poor body image: I care more about my health and what my body can do than what it looks like. I was raised under the notion of “health at every size,” in which each person has a given weight “set point” that does not necessarily fall within the designated standardized “healthy” or “ideal” weight ranges. I have always believed that if one eats and lives healthfully, then his or her weight itself should not be problematic. Weight is not tantamount to health—a thin individual may be just as unhealthy as an average or overweight individual, depending on his or her diet, activity level, and overall way of life. Consequently, I have never worried about my underweight body: I have assumed that, since I follow a healthy lifestyle, my stable but low weight should not be of much concern. Clearly, Dick’s House possessed a different standpoint.

Upon returning home, I discussed the situation with my parents, who were appalled at my treatment and at the haste and inaccuracy of the school health clinic. We had pondered the upsetting circumstances for a brief period, when the college counselor, as head of my case, called. I answered the call and swiftly handed the phone to my parents, whom I hoped would help explain this terrible misunderstanding. Alas, my exhausted mother only managed to half-yell at the counselor, who repeated some spiel about my inability to function and the importance of entering what I now understood was an eating disorder facility. My father’s reaction was much calmer but received a similar response. The counselor refused to consider that the health clinic had misdiagnosed me—I, undoubtedly, had an eating disorder and needed to be re-fed and monitored in a facility until I reached a healthier state. This disturbing conversation spurred a month-long expedition involving countless appointments with physicians and specialists, from a gastroenterologist and nutritionist to clinical social workers and a psychiatrist. Glancing at the lab results from the health clinic, no medical professional understood the volatile reaction that culminated in my withdrawal. Furthermore, a repeat of blood work revealed that my phosphate levels were normal; my slightly low levels of phosphorus presented in the earlier labs from Dick’s House supposedly were dangerous and indicated that my health was in jeopardy. Examinations by my doctors at home revealed that my health was, in fact, in no danger, and that I was healthy and capable of functioning. Moreover, specialists in behavioral health confirmed that I (as expected) did not have an eating disorder. In an attempt to bring the injustice of my misdiagnosis and maltreatment to the attention of the directors of the college health clinic, my family wrote a letter outlining the series of events that preceded my withdrawal and expressing our complaints. We received a reply indicating that my case would be reassigned to one of the co-directors of medical services. Though I would have preferred a response along the lines of, “We’re sorry about this misunderstanding and will immediately clear you for readmission for fall term,” I was not so deluded as to expect such an apologetic response. Nevertheless, the reply suggested that my situation would be managed seriously and, hopefully, fairly.

A letter delivered in the mail a few days later suggested otherwise. Signed by both the counselor and, to my dismay, the co-director of medical services to whom my case had been reassigned, the letter described the events leading to my withdrawal—much like my family’s letter, but from a significantly different perspective. It also delineated a treatment plan that I would have to follow in order to receive readmission to Dartmouth. Reading the health clinic’s perspective of my circumstances, I was horrified. I realized that essentially every symptom they cited as evidence for my “eating disorder” was inaccurate and distorted: my BMI was calculated using an incorrect height; I was purported to exhibit lanugo, amenorrhea, and low body temperature, all of which I do not have; and “reports” that I supposedly gave them were misinterpreted to support their diagnosis. Furthermore, the letter mentioned not only my most recent visit to the health clinic, but also a visit that occurred during my freshman year when I, similarly, had experienced fatigue and suspected anemia. Though I do not clearly recall this visit, it appears that I had met with the woman now heading my case, who had also expressed concern about my weight at the time and recommended that I see a nutritionist. I had felt as if I was being treated like someone with an eating disorder; consequently, I avoided returning to the clinic. Unfortunately, this memory was not sufficiently vivid to prevent me from scheduling my most recent appointment. Noticing that the letter emphasized my initial visit in 2012, I arrived at a disturbing realization: like an animal, I had been “tagged” from the start. The health clinic noted my low weight and immediately marked me as an at-risk student to be under their intense scrutiny. The only possible way that I could have perhaps avoided them was by never returning to the health clinic. How naïve I was to care about my health and to seek help, only to encounter discrimination—not the typical hatred of fat that is so pervasive in the United States, but a bias against those on the other end of the weight continuum, against those who are thin. My battle against the health clinic would never be fair: they would never be able to see beyond their limited viewpoint, to look beyond the number on the scale. Yet, I was trapped in this situation, incapable of totally escaping the demands of the health clinic if I truly wanted to return to college and continue my education, on which I place such great value. Thus, I had no other option but to suppress my outrage and to abide by the system, despite the distress and resentment that hid behind my calm and polite demeanor. I had to listen to the new manager of my case and negotiate with her, to humor the health clinic and its distorted perceptions.

Around the same time that I received the letter, my case manager contacted me to initiate a process through which she would speak with my providers, the countless doctors and specialists that I had visited. A few of these providers called me after their conversation and informed me of their discussion, noting several particularly perturbing comments expressed by my case manager. Perhaps the most unsettling claim was that I “was not functioning.” As a straight-A student and twice-acknowledged Rufus Choate Scholar, I had been excelling in my classes; furthermore, I had been participating in a variety of extracurricular activities. It was completely fallacious and offensive to assert that I was not functioning—not only was I functioning, but I was thriving in college. With the exception of my recurrent anemia and occasional fatigue, I was functioning quite well. Yet, the health clinic appeared to define “functioning” in a most peculiar way: “functioning,” apparently, was contingent upon weight. The claim that I was “not functioning” merely referred to the fact that I was underweight.

The stressful situation dragged on as my case manager waited to contact all of my providers, many of whom were quite busy. Only after she was able to reach every individual did she begin to specify the “treatment plan” to which I was to adhere upon my readmission to Dartmouth. The very thought of a treatment plan enraged me, as I knew—as did my providers—that I was healthy: I needed no treatment. However, because the health clinic refused to apologize and recognize their error, it was I who had to suffer. I was later informed that my “treatment plan” would consist of appointments with a therapist and with a nutritionist, who would monitor my weight, to ensure that I could achieve “optimal health” while on campus. Health, of course, equated to a normal body weight, and only to a normal body weight. Despite the complimentary and kind words spoken by my case manager during our phone conversations and discussions of my treatment plan, I was not to delude myself into thinking that the health clinic actually cared about me or my health. If the health clinic had cared about my health, they would have been more concerned with my lifestyle choices than with some number on a scale; I could have been completely sedentary and subsisted on a diet of junk food, and the health clinic would have been content had I had a normal body weight. Had the health clinic cared about my health, they would not have so hastily thrown me out of school and accused me of having an eating disorder, an accusation that has profound consequences both psychologically and physiologically for the patient. The health clinic did not care that my family and I went through complete hell that summer; they did not care that I missed out on a term that I had so eagerly anticipated, only to receive negative attention and undergo countless unpleasant procedures; they did not care about the emotional anguish that my family and I endured, the chronic worrying and anxiety produced by their mistaken conclusion.

Although I indulged the health clinic and their flawed perceptions and demands, I refuse to simply let such an unfair incident pass unnoticed: this injustice has major implications and must be revealed to the public. I do not consider my treatment unjust merely because it was I who suffered, but because it was a human who suffered. A healthy student should never be kept from their education due to their weight, an arbitrary number that, alone, cannot be used to assess their wellbeing. No individual deserves to endure discrimination. Perhaps the two resonant themes that have emerged throughout my story are that weight is not indicative of health, and, relatedly, that an individual should never be judged by their weight. Just because I am skinny does not indicate that I have an eating disorder; just because someone is overweight does not indicate that they are lazy or unfit. The notion of health at every size is not some flippant medical claim or fad-like philosophy, but an accurate and necessary recognition of the relativity of health: each person has a unique body which has its own individual needs and set point that cannot be generalized to an entire population. Instead of condemning our bodies for being too thin or too flabby, we should marvel at their strength, endurance, and capabilities. It is through these bodies that we live and experience the world, that we create and become ourselves and find meaning in life. We should tend to our bodies and health to enjoy life and to enable us to fulfill our true potentials as human beings—but nowhere in these potentials is there some “ideal” weight that all must achieve. Paradoxically, both in spite of and considering my experience, I am more determined than ever to understand and savor life, to appreciate my body and its amazing capabilities; and if this body is slightly underweight, I love it anyway, regardless of the critiques of a few so-called “health professionals.”

POSTSCRIPT:

As I have completed the remainder of my undergraduate education at Dartmouth, I have come to realize that my situation was not entirely unique. Many friends and acquaintances with whom I’ve discussed my experience have relayed similar stories of misdiagnosis, maltreatment, and neglect at the hands of the school health clinic. While my essay has emphasized the unfortunate reality of discrimination based on one’s body type, the stories of my fellow students raise a more general concern: the inadequacy of current student health services for tending to their patients’ wellbeing. It is disappointing and appalling to recognize that college health clinics---even those found at Ivy League Institutions---fail to consider, diagnose, and treat students as individuals and care more to absolve themselves of liability than to sincerely aid their patients. When the student is seen more as a nuisance and threat to the medical clinic than as a valuable individual worthy of respect and proper treatment, one should question the degree to which the clinic is promoting health at all. While now, having graduated from Dartmouth, I no longer need concern myself with Dick’s House, these problems demand recognition and must be addressed to ensure that students receive the medical care which they truly deserve.

POST-POSTSCRIPT:

My views on “health at every size” have changed slightly over time. Now that I have managed to attain a more “healthy” body weight, I realize that I am probably in a safer place now than I was before. While I did not have an eating disorder and was not intentionally trying to maintain a low body weight at the time, I partook in excessive long-distance running. I speculate that, despite eating a lot, between my high level of physical activity and lingering malabsorption problems, I could not provide my body with sufficient calories to gain weight. I still consider weight and body mass index (BMI) to generally be terrible indicators of health, as body composition (how much muscle and fat one has) and lifestyle choices are far more important; however, being extremely underweight or overweight can be risky in itself.

I graduated in 2016 as salutatorian of the class.