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Cesarean Scar Pregnancy: Another Complication on the Rise from High Cesarean Rates

2013-06-18T21:07:20-07:00

Cesarean Scar Pregnancy, Kung 2006

As a follow-up to Cesarean Awareness Month, we have been focusing on some of the rarer possible downstream complications of cesareans. Today we discuss Cesarean Scar Pregnancies. Warning ─ this one's not for the faint of heart.

Again, I would reiterate that many cesareans are truly life-saving and necessary, and many others are probably prudent. However, cesareans are not without risks and should not be done lightly. The extremely high cesarean rates in certain areas of this country and around the world has very distinct public health implications, both in the immediate period around the cesarean and for years afterwards. In particular, the long-term implications of cesareans are under-recognized.

We've already discussed abnormal placental implantation (placenta previa, placenta accreta, placenta increta, placenta percreta), which is one of the most significant risks to future pregnancies after cesarean section. As a follow-up to this, we also discussed placenta previa in more detail.

Another potential very serious complication of pregnancies after prior cesarean is an ectopic pregnancy in the cesarean scar itself.

Cesarean Scar Pregnancy

An "ectopic" pregnancy is one that implants outside of the uterus. Most often, ectopic pregnancies are tubal (in the Fallopian tubes), but sometimes they occur outside of uterus in the abdomen, in the cervix, etc.

However, with the rise in cesarean rates, care providers are now seeing an increase in the previously extremely rare situation of an ectopic pregnancy implanting in the cesarean scar.

This is called Cesarean Scar Pregnancy, or CSP.

The main symptom is usually vaginal bleeding during early pregnancy; sometimes this is painless and sometimes it is accompanied by significant abdominal pain. Very high hCG levels are another symptom that raises the suspicion for CSP. However, some women with CSP have no obvious symptoms at first.

Since many pregnancies experience early spotting, most women don't take vaginal bleeding in the first trimester too seriously. However, women with a prior cesarean and significant bleeding/abdominal pain may want to consider an early vaginal ultrasound, just in case, especially if it is accompanied by very high hCG levels.

A few care providers feel that every women with a prior cesarean should have an ultrasound in very early pregnancy to check for CSP, although this is by no means standard. The downside to this, of course, is that any prenatal testing carries with it potential for false positives and unnecessary worry.

If you do choose to have an ultrasound in early pregnancy after a prior cesarean, certain things should be checked for. According to a recent 2012 review, the following sonographic findings should raise the suspicion level for a Cesarean Scar Pregnancy:

No fetal parts in the uterine cavity or cervix
A thin myometrial layer between the bladder and gestational sac
A triangular-shaped gestational sac
A gestational sac that is close to the bladder and uterine wall
Presentation of arteriovenous malformation in the area

Because the non-sonographic symptoms are unclear and easy to ignore at first, many cases of CSP go undetected initially. Even when the patient presents with symptoms to a care provider, the diagnosis may be missed; the 2012 review found that about 13% of CSP are missed or misdiagnosed at first.

Thus, some CSP patients only get recognized once the uterus has ruptured and they are in hypovolemic shock. Many of these patients have to undergo a hysterectomy to stop the bleeding.

Bottom line, the longer a Cesarean Scar Pregnancy continues, the worse the outcome in most cases. Therefore, most resources agree that it's important to recognize and deal with a CSP as early as possible. If the CSP is caught early, outcomes improve and fertility can often be preserved.

Transvaginal ultrasound is usually reasonably accurate for diagnosing CSP, although the diagnosis can still be missed even with ultrasound. Often color flow Doppler imaging is helpful. Occasionally an MRI may be used if other results are ambiguous.

Prior cesarean is not the only risk factor for Cesarean Scar Pregnancy. A history of uterine infections and prior D&C procedures are also risk factors, as is a short inter-pregnancy interval after a cesarean. Treatment with In Vitro Fertilization may also be associated with CSP, although this is not clear. Some authors have speculated that recent uterine suturing technique changes (single-layer, various suture materials) may also have an effect, though there is little data to support or refute this.

Obviously having a prior cesarean scar is the most important risk factor for CSP.

Ethical Dilemmas

When CSP occurs, nearly all clinicians believe that there is little choice but to end the pregnancy because the growing pregnancy will quickly become life-threatening to the mother, and the fetus is extremely unlikely to survive anyhow. This places parents in the very difficult position of having to make a choice to end a pregnancy in order to save the life of the mother.

A few providers have managed a Cesarean Scar Pregnancy expectantly. This has been done for those who object to termination under any circumstances, in parents who hope to avoid the difficult choice to end a pregnancy, or in hopes that the pregnancy will move into the uterus with time and become viable.

Since a Cesarean Scar Pregnancy is rarely sustainable and will often miscarry on its own with time; some parents hope that taking a wait-and-see approach can relieve them of the difficult choice to end a pregnancy. However, this approach does present significant risk to the mother.

There have been a few extremely rare instances of Cesarean Scar Pregnancies that resulted in viable infants. Usually these are pregnancies where the gestational sac grows towards the uterus, eventually becoming mostly intrauterine pregnancies. Even then, most doctors recommend a planned cesarean at 28-30 weeks as a precaution against later uterine rupture, and usually assume that placenta accreta accompanies the CSP (making hysterectomy a distinct possibility).

Continuing the pregnancy in hopes of being the rare exception that results in a live baby is understandable but risks life-threatening complications because uterine rupture is very common as a CSP progresses. The 2012 review notes that patients advised to take a "wait and see" approach often ended up with an emergency hysterectomy and infant death anyhow.

There are no easy choices here. Women need to know that the further a Cesarean Scar Pregnancy progresses, the riskier the outcome. As one study points out:

It is likely that if a developing pregnancy in a caesarean section scar were to continue to the second or third trimesters, there would be a substantial risk of uterine rupture with catastrophic haemorrhage, with a high risk of hysterectomy causing serious maternal morbidity and loss of future fertility. There is also a danger of invasion of the bladder by the growing placenta. A pregnancy that protrudes through the scar, if viable, can implant on other abdominal organs and continue to grow as a secondary abdominal pregnancy.

As a result, women may experience uterine rupture, major hemorrhages, and internal damage to nearby organs. Many lose their fertility permanently via hysterectomy. Occasionally, women have lost their lives with a Cesarean Scar Pregnancy, although this is very unusual in developed countries now because of the use of ultrasound for early detection.

Clearly, this is a dilemma with far-reaching consequences and there are no easy answers.

Treatment

Cesarean Scar Pregnancy Diagram, Zhang 2012

Most clinicians believe that the only reasonable treatment for a Cesarean Scar Pregnancy is to end the pregnancy, but the best method for that is still being debated.

There are a wide variety of treatments used for CSP, including D&C, systemic methotrexate, local injection of methotrexate, Uterine Artery Embolization, laparoscopic or hysteroscopic surgical treatments, and others. The relative rarity of CSP makes it hard to know which approach is best and therefore the standard of care on this is still evolving.

A 2012 survey of case reports in the medical literature found that there has been a huge variety of treatments for Cesarean Scar Pregnancies, but that many resulted in significant morbidity (44%). They reviewed the various treatments used and analyzed the results.

According to the 2012 survey, D&C (Dilation and Curettage) was the most common treatment used for CSP, but it was associated with high rate complications (nearly 62%), and often resulted in hemorrhage. The authors concluded that this was not a good choice for treatment of a CSP.

The authors also found that giving methotrexate systemically to the mother was associated with a 62% morbidity rate. This was because secondary treatments were often needed and these had a high complication rate. The authors recommended against this treatment too.

In Uterine Artery Embolization (UAE), an interventional radiologist inserts a small catheter into an artery in the leg, runs it up to the arteries that feed the uterus, and injects small particles to reduce blood flow to the uterus. UAE had a complication rate of 46%, so the authors recommended against UAE as a single treatment for CSP. However, UAE is often used in conjunction with or after other therapies to help reduce severe bleeding.

Operative hysteroscopy (examination of the inside of the uterus with a fiber-optic tube inserted via the cervix, then surgical intervention as needed) had a much better complication rate of 18%.

Injecting methotrexate directly into the gestational sac was the treatment associated with the least maternal morbidity in the review. When combined with an intramuscular injection of methotrexate, the complication rate was slightly less than 10%. After this injection, the body slowly breaks down the leftover tissues, so treatment must be followed long-term to be sure everything is resolving fully, but there is less need for surgical intervention and all its risks.

One problem was that many care providers did not realize that methotrexate treatment results in a temporary increase in hCG levels, leading them to use secondary interventions that led to complications:

Many of the complications reported in the literature review resulted because clinicians were not aware that increases in hCG concentrations could be expected with the treatment, Dr. Timor-Tritsch noted.

"Many secondary treatments were triggered not by bleeding, but by the observation of a post-treatment increase the hCG cycle and vascularity," he said. "The treatments often resulted in escalation of the critical situation and often hysterectomy."

"Knowledge of the naturally occurring increase of the hCG volume in blood vessels with a slow resolution could have avoided a secondary resolution," Dr. Timor-Tritsch said.

Other treatment options include laparotomy or laparoscopy. This is a surgical excision of the gestational sac and repair of the uterus via opening the abdomen up (laparotomy) or doing the surgery through a small hole in the abdomen (laparoscopy).

After a cesarean scar pregnancy, it may take a while for the mother to recover. Bleeding may continue off and on for quite a while. Treatment with methotrexate often takes several months to resolve the situation ─ in some reports, it took up to a year. Often follow-up testing is needed. And of course, emotional support is needed, since the parents have just been through a very difficult ordeal.

Although most women with a CSP do not choose to have another pregnancy, some do. If the CSP was caught early enough and their uterus was able to be preserved, subsequent pregnancy is certainly possible. Researchers generally suggest that the mother wait a good while before trying to conceive again, since closely-spaced pregnancies may be a risk factor for CSP. Furthermore, if methotrexate or other drugs were part of the treatment, it may take a while for all traces of these drugs to be out of the mother's body. So waiting a while before attempting to conceive again may be a good idea.

Although there are risks, outcomes are reasonably good in pregnancies after CSP. Most authors recommend careful early surveillance of a post-CSP pregnancy in case of repeat Cesarean Scar Pregnancy or abnormal placentation. There is a somewhat higher rate of miscarriage and repeat CSP, and the risk for uterine rupture and placenta accreta is also higher. Case reports have occasionally recorded deaths in mother and/or baby due to uterine rupture in a pregnancy after CSP, so careful monitoring of the pregnancy may be appropriate.

Many post-CSP pregnancies are delivered by planned repeat cesarean section because of the perceived potential for uterine rupture, although it is difficult to estimate the actual risk for uterine rupture under these circumstances. On the other hand, some authors advocate for vaginal birth in order to avoid further scarring of the uterus. The number of pregnancies after prior CSP is so small that it's difficult to draw any conclusions about the best course of action.

Incidence of Cesarean Scar Pregnancy

Although Cesarean Scar Pregnancy is thankfully still rare, it is on the rise, and likely will continue to rise in parallel with cesarean rates.

Of course, it's important to note that absolute numerical risk of this complication is low. Very few women with prior cesareans experience this complication. Therefore, as an individual mother, it's unlikely that you would experience a cesarean scar pregnancy.

However, from a public health point of view, it's also important to note that the more cesareans that are done world-wide, the more women are susceptible to this problem and the more cesarean scar pregnancies we will see, even while they remain a rare risk for any one individual.

The incidence of Cesarean Scar Pregnancy (CSP) is difficult to pinpoint because of its relative rarity and the diversity of baseline cesarean rates in various areas. This is also a fairly new area of research, with mostly case reports rather than population-wide studies.

But its increase can be noted if you look closely at the research. One 2002 study notes, "Only 19 cases have been reported in the English medical literature since 1966."

However, a 2004 study, only two years later, looked for case reports that were made after 2002, and found 66 new case reports in only two years. A recent 2012 survey of the literature found 751 case reports. Obviously, the incidence appears to be on the rise.

The increase in case reports may be partly due to higher cesarean rates, but also is probably due to increased awareness of CSP and a willingness to document them as a complication of prior cesareans. But there's little doubt doctors are seeing them in greater numbers than in the past.

Exact numbers will depend on the study and the underlying risk factors of the population, such as how high its cesarean rate is, how many women have been exposed to D&C (another risk factor for CSP), the usual parity of the population etc. Even so, some general numbers can be found.

One review found a rate of 1 cesarean scar pregnancy per 1800 - 2200 normal pregnancies (all pregnancies, prior cesarean or not). Another study found a similar rate of 1 CSP per 1800 normal pregnancies.

However, that doesn't tell you what your risk for CSP is if you've had a prior cesarean.

An Israeli study found the CSP rate more along the lines of 1 CSP per 3000 normal pregnancies, but this dropped to a rate of 1 CSP per 531 pregnancies in women who had had cesareans in the past.

Rounded up slightly, about 0.2% of women who had cesareans experienced a Cesarean Scar Pregnancy in a later pregnancy.

Interestingly, this is beginning to approach the incidence of uterine rupture in spontaneous labor among women with a prior cesarean (which is generally around 0.4 - 0.5%).

Interestingly, about half the time Cesarean Scar Pregnancy occurred in a woman with only one prior cesarean. It is not clear from research whether multiple prior cesareans increases the risk for CSP, but it is clear that when CSP does occur, it can happen in women with only one prior cesarean.

That's why preventing every unnecessary cesarean matters.

Conclusion

Cesarean Scar Pregnancy is an extremely serious problem. Although rare, its incidence is on the rise in parallel with the high rate of cesareans being done these days.

Because it is rare, this is not a complication that individual mothers with a history of prior cesarean should lose much sleep over. However, from a public health point of view, it is a concern.

Because many cesareans are done because of VBAC bans, out of fear of liability, for convenience, as a routine repeat cesarean, or for other questionable indications, the increasing rate of Cesarean Scar Pregnancy is a sadly avoidable nightmare in many cases.

This is yet another reason why it's so important to care providers to make sure that Vaginal Birth After Cesarean remains accessible, and why they need to prevent as many unnecessary first cesareans as possible.

References

General Resources on Cesarean Scar Pregnancy

Increased Incidence of Cesarean Scar Pregnancies

Obstet Gynecol Surv. 2002 Aug;57(8):537-43. Ectopic pregnancy within a cesarean scar: a review. Fylstra DL. PMID: 12187153

Implantation of a pregnancy within the scar of a previous cesarean delivery is the rarest of ectopic pregnancy locations. Only 19 cases have been reported in the English medical literature since 1966. If diagnosed early, treatment options are capable of preserving the uterus and subsequent fertility. However, a delay in either diagnosis or treatment can lead to uterine rupture, hysterectomy, and significant maternal morbidity. Although expectant and medical managements have been reported, termination of a cesarean scar pregnancy by laparotomy and hysterotomy, with repair of the accompanying uterine scar dehiscence, may be the best treatment option.

Hum Reprod Update. 2004 Nov-Dec;10(6):515-23. Epub 2004 Sep 16. Ectopic pregnancies in a Caesarean scar: review of the medical approach to an iatrogenic complication. Maymon R, Halperin R, Mendlovic S, Schneider D, Herman A. PMID: 15375087

...Sixty-six new cases were reported since 2002, possibly reflecting the increasing number of Caesareans currently being performed as well as the more widespread use of the transvaginal scan allowing their earlier detection. Analysis of these women's obstetric history revealed that those at risk for pregnancy in a Caesarean scar appear to have a history of dilatation and curettage, placental pathology, ectopic pregnancy, and IVF. Twenty-one out of 39 for which this information was available (54%) had undergone multiple (> or =2) Caesareans and 13 had previous dilatation and curettage, which might also be an associated factor....

J Ultrasound Med. 2012 Sep;31(9):1449-56. Cesarean scar pregnancy: sonographic and magnetic resonance imaging findings, complications, and treatment. Osborn DA, Williams TR, Craig BM. PMID: 22922626

A cesarean scar (ectopic) pregnancy occurs when a pregnancy implants on a cesarean scar. This condition is an uncommon but potentially devastating occurrence. The incidence is increasing as cesarean deliveries become more common. Early recognition of the salient sonographic findings is critical because a delay can lead to increased maternal morbidity and mortality. Magnetic resonance imaging is a valuable troubleshooting tool when sonography is equivocal or inconclusive before therapy or intervention. Early diagnosis by sonography directs therapy and improves outcomes by allowing preservation of the uterus and future fertility. We review the imaging features, differential diagnosis, complications, and treatment of cesarean scar pregnancies in the first trimester.

J Clin Ultrasound. 2007 May;35(4):212-5. Sonographic diagnosis of cesarean scar pregnancy at 16 weeks. Smith A, Ash A, Maxwell D. PMID: 17366559

Cesarean scar pregnancy is rare. However, there has been a rapid increase in the reporting of such cases in recent years. Most of the cases reported in the literature were diagnosed early in the first trimester. Possible management options proposed are pertinent to an early diagnosis. We present a case of a cesarean scar pregnancy diagnosed at 16 weeks that posed a dilemma with regard to management. The patient subsequently suffered a ruptured uterus, which was preserved at surgery.

J Clin Ultrasound. 2008 Oct;36(8):504-11. doi: 10.1002/jcu.20471. First-trimester diagnosis of cesarean scar ectopic pregnancy. Moschos E, Sreenarasimhaiah S, Twickler DM. PMID: 18393379

Once considered extremely rare, implantation of a pregnancy within the scar of a previous cesarean section is becoming more common. In fact, its incidence is now higher than that of cervical ectopic pregnancies. We identified 5 cases of ectopic pregnancy implanted in a prior cesarean section scar at our institution since 2004. We outline the criteria for the first-trimester sonographic diagnosis of cesarean scar ectopic pregnancy, including a new sign of lower uterine segment ballooning, which has previously not been reported. Clinicians must have a heightened awareness of this serious and potentially fatal pregnancy complication.

J Ultrasound Med. 2011 Sep;30(9):1179-84. Fertility performance and obstetric outcomes among women with previous cesarean scar pregnancy. Maymon R, Svirsky R, Smorgick N, Mendlovic S, Halperin R, Gilad K, Tovbin J. PMID: 21876087

...METHODS: We conducted a retrospective study in a large tertiary hospital in Israel. The study included 18 women with a diagnosis of cesarean scar pregnancy between 2000 and 2009. RESULTS: The incidence of cesarean scar pregnancy among our parturient patients was 1 per 3000 for the general obstetric population and 1 per 531 among those with at least 1 cesarean delivery. Sixteen were treated primarily with methotrexate. Two were treated primarily by surgery, and 2 more were treated by surgery after failed methotrexate treatment. After cesarean scar pregnancy treatment, 7 women conceived spontaneously, and 1 conceived by in vitro fertilization-intracytoplasmic sperm injection. The remaining 10 (55%) did not wish to conceive again. Two of the women who became pregnant (25%) had recurrent cesarean scar pregnancy. CONCLUSIONS: This study shows encouraging results for fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy. Nevertheless, the risk of recurrent cesarean scar pregnancy is not negligible.

Obstet Gynecol. 2006 Jun;107(6):1373-81. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Rotas MA, Haberman S, Levgur M. PMID: 16738166

...Fifty-nine articles that met the inclusion criteria provided data on the clinical presentation, diagnosis, and treatment modalities of 112 cases of cesarean delivery scar pregnancies. TABULATION, INTEGRATION, AND RESULTS: Review of the 112 cases revealed a considerable increase in the incidence of this condition over the last decade, with a current range of 1:1,800 to 1:2,216 normal pregnancies. More than half (52%) of the reported cases had only one prior cesarean delivery. The mean gestational age was 7.5 +/- 2.5 weeks, and the most frequent symptom was painless vaginal bleeding...Expectant management of 6 patients resulted in uterine rupture that required hysterectomy in 3 patients. Dilation and curettage was associated with severe maternal morbidity. Wedge resection and repair of the implantation site via laparotomy or laparoscopy were successful in 11 of 12 patients. Simultaneous administration of systemic and intragestational methotrexate to 5 women, all with beta-hCG exceeding 10,000 milli-International Units/mL required no further treatment. CONCLUSION: Surgical treatment or combined systemic and intragestational methotrexate were both successful in the management of cesarean delivery scar pregnancy. Because subsequent pregnancies may be complicated by uterine rupture, the uterine scar should be evaluated before, as well as during, these pregnancies.

Management of Cesarean Scar Pregnancy

Ultrasound Obstet Gynecol. 2003 Mar;21(3):220-7. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar. Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. PMID: 12666214

...The management of Cesarean section scar pregnancies included transvaginal surgical evacuation, medical treatment with local injection of 25 mg methotrexate into the exocelomic cavity and expectant management. RESULTS: Eighteen Cesarean section scar pregnancies were diagnosed in a 4-year period. The prevalence in the local population was 1 : 1800 pregnancies. Surgical treatment was used in eight women and it was successful in all cases. The respective success rates of medical treatment and expectant management were 5/7 (71%) and 1/3 (33%). Five women (28%) required blood transfusion and one woman (6%) had a hysterectomy. CONCLUSIONS: Cesarean section scar pregnancies are more common than previously thought. When the diagnosis is made in the first trimester the prognosis is good and the risk of hysterectomy is relatively low.

Curr Opin Obstet Gynecol. 2011 Dec;23(6):415-21. doi: 10.1097/GCO.0b013e32834cef0c. Caesarean scar pregnancy: a review of management options. Litwicka K, Greco E. PMID: 22011956

...CSP is a type of ectopic gestation associated with a high risk of serious complications. The cause of this condition and the best management are still unclear. However, some medical and surgical treatment modalities have been suggested. The main objectives in the clinical management of CSP should be the prevention of massive blood loss and the conservation of the uterus to maintain further fertility, women's health and quality of life. Current data suggest that expectant management should not be recommended, whereas there are accumulating data suggesting that early diagnosis offers single or combined medical and surgical treatment options avoiding uterine rupture and haemorrhage, thus preserving the uterus and fertility. SUMMARY: No universal treatment guidelines for the management of CSP have been published up to now. The lack of data on the best evidence should encourage any individual case report and further multicentre studies for recommendations establishment.

Clin Perinatol. 2008 Sep;35(3):519-29, x. doi: 10.1016/j.clp.2008.07.003. Placenta accreta and cesarean scar pregnancy: overlooked costs of the rising cesarean section rate. Rosen T. PMID: 18952019

An unintended consequence of the rising cesarean section rate is abnormal placentation in subsequent pregnancies, leading to the clinical complications of placenta accreta and cesarean scar pregnancies. Both of these clinical entities are associated with high rates of maternal morbidity and mortality. This article reviews the potential mechanisms by which uterine scarring may lead to abnormal trophoblast invasion, the association of cesarean section with placenta accreta and scar pregnancies, current management, and suggestions for future research to reduce the incidence of these potentially devastating complications of pregnancy.

Am J Perinatol. 2010 Feb;27(2):111-20. doi: 10.1055/s-0029-1224874. Epub 2009 Jun 5. Cesarean scar ectopic pregnancy: case series and review of the literature. Sadeghi H, Rutherford T, Rackow BW, Campbell KH, Duzyj CM, Guess MK, Kodaman PH, Norwitz ER. PMID: 19504427

...We present four cases of cesarean scar ectopic pregnancy diagnosed within a 6-month period between 2007 and 2008. Their initial presentations and management are discussed, followed by a review of the published literature summarizing both diagnostic and management recommendations.

BJOG. 2007 Mar;114(3):253-63. Caesarean scar pregnancy. Ash A, Smith A, Maxwell D. PMID: 17313383

...Transvaginal ultrasound and colour flow Doppler provides a high diagnostic accuracy with very few false positives. A delay in diagnosis and/or treatment can lead to uterine rupture, major haemorrhage, hysterectomy and serious maternal morbidity. Early diagnosis can offer treatment options of avoiding uterine rupture and haemorrhage, thus preserving the uterus and future fertility. Management plan should be individually tailored. Available data suggest that termination of pregnancy is the treatment of choice in the first trimester soon after the diagnosis. Expectant treatment has a poor prognosis because of risk of rupture. There are no reliable scientific data on the risk of recurrence of the condition in future pregnancy, role of the interval between the previous caesarean delivery and occurrence of caesarean scar pregnancy, and effect of caesarean wound closure technique on caesarean scar pregnancy. In this article, we aim to find the demography, pathophysiology, clinical presentation, most appropriate methods of diagnosis and management, with their implications in clinical practice for this condition.

J Reprod Med. 2011 Jul-Aug;56(7-8):356-8. Cesarean scar ectopic pregnancy: a case report of failed combination local and systemic methotrexate management requiring surgical intervention. Stevens EE, Ogburn P. PMID: 21838169

BACKGROUND: Cesarean scar ectopic pregnancies have been diagnosed with increasing frequency in the last decade. There is no consensus of management for these pregnancies; however, prior reports have suggested best results using either combination methotrexate therapy or surgical excision. CASE: We present a case of failed systemic and local methotrexate therapy requiring operative management. CONCLUSION: Cesarean scar ectopic pregnancies can have disastrous outcomes, including uterine rupture, massive hemorrhage and maternal death. Although this is the first case to report a failure of the combination therapy, major morbidities did not occur. We believe this is due to our choice of expedient surgical management.

J Obstet Gynaecol. 2012 Oct;32(7):621-3. doi: 10.3109/01443615.2012.698665. Caesarean scar pregnancy: a precursor of placenta percreta/accreta. Sinha P, Mishra M. PMID: 22943704

In the last decade, diagnosis of caesarean scar (CS) pregnancy and abnormal placental invasion has gone up significantly. It appears that the history of previous caesarean section is the predisposing factor common to both conditions. Until now, these are treated as a separate entity and therefore managed differently. Recent available evidence suggests that these are not a separate entity but rather a continuum of the same condition. If the caesarean scar pregnancy is managed expectantly in the 1st trimester, most likely it evolves into placenta accreta. This leads invariably to peripartum hysterectomy for postpartum haemorrhage (PPH) and severe maternal morbidity. Early diagnosis and intervention may give a favourable outcome.

Ultrasound Obstet Gynecol. 2004 Mar;23(3):247-53. Cesarean scar pregnancy: issues in management. Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. PMID: 15027012

...METHODS: During a 6-year period, 12 cases of Cesarean scar pregnancy were diagnosed using transvaginal color Doppler sonography and treated conservatively to preserve fertility...RESULTS: The incidence of Cesarean scar pregnancy was 1:2216 and its rate was 6.1% in women with an ectopic pregnancy and at least one previous Cesarean section...Patients were treated as follows: transvaginal ultrasound-guided injection of methotrexate into the embryo or gestational sac (n = 3), transabdominal ultrasound-guided injection of methotrexate (n = 2), transabdominal ultrasound-guided injection of methotrexate followed by systemic methotrexate administration (n = 2), systemic methotrexate administration alone (n = 2), dilatation and curettage (n = 2), or local resection of the gestation mass (n = 1). Eleven of the 12 patients preserved their reproductive capacity; the remaining patient, treated by dilatation and curettage, underwent a hysterectomy because of profuse vaginal bleeding. The Cesarean scar mass regressed from 2 months to as long as 1 year after treatment. Uterine rupture occurred in one patient during the following pregnancy at 38 + 3 weeks' gestational age. CONCLUSION: Ultrasound-guided methotrexate injection emerges as the treatment of choice to terminate Cesarean scar pregnancy. Surgical or invasive techniques, including dilatation and curettage are not recommended for Cesarean scar pregnancy due to high morbidity and poor prognosis.

BJOG. 2011 Aug;118(9):1136-9. doi: 10.1111/j.1471-0528.2011.02891.x. Epub 2011 Apr 12. Transvaginal removal of ectopic pregnancy tissue and repair of uterine defect for caesarean scar pregnancy. He M, Chen MH, Xie HZ, Yao SZ, Zhu B, Feng LP, Wu YP. PMID: 21481146

From December 2009 to April 2010, six patients with caesarean scar pregnancies (CSPs) underwent the transvaginal removal of ectopic pregnancy tissue and repair of a uterine defect. Transvaginal surgery was performed uneventfully in all cases. The operating time ranged from 45 to 80 minutes. Blood loss ranged from 50 to 150 ml. Serum β-hCG (β-subunit of human chorionic gonadotrophin) levels declined to normal levels within a month for all patients, and all patients recovered without complications. Our results show that the transvaginal removal of ectopic pregnancy tissue and repair of the uterine defect is effective, safe, and minimally invasive for patients with CSP.

J Obstet Gynaecol Res. 2007 Dec;33(6):873-7. Three-dimensional ultrasonographic diagnosis and hysteroscopic management of a viable cesarean scar ectopic pregnancy. Ozkan S, Calişkan E, Ozeren S, Corakçi A, Cakiroğlu Y, Coşkun E. PMID: 18001457

...No therapeutic modality is suggested to be entirely efficacious and safe for preserving uterine integrity. We present here a 29-year-old woman with vaginal bleeding and a gestational sac with a viable embryo of 6 weeks of age that was implanted in a cesarean section scar. Serum beta-hCG levels were 16 792 mIU/mL. Following an unsuccessful treatment course of systemic methotrexate, the patient underwent operative hysteroscopy. Minimally invasive hysteroscopic resection of the ectopic gestational mass without major complication appears to be an alternative therapeutic approach with minimal morbidity and preservation of future fertility.

Am J Obstet Gynecol. 2012 Nov;207(5):386.e1-6. doi: 10.1016/j.ajog.2012.09.012. Epub 2012 Sep 17. Bilateral uterine artery chemoembolization with methotrexate for cesarean scar pregnancy. Shen L, Tan A, Zhu H, Guo C, Liu D, Huang W. PMID: 23107082

OBJECTIVE: The objective of the study was to assess the efficacy of uterine arteries embolization (UAE) for the treatment of cesarean scar pregnancies (CSP). STUDY DESIGN: Forty-six women with CSP were identified between March 2008 and March 2010. All of the patients underwent UAE combined with local methotrexate. RESULTS: Forty-five patients were successfully treated. One patient had an emergency hysterectomy after 20 days because of massive vaginal hemorrhage. The mean time until normalization of serum β-human chorionic gonadotrophin was 37.7 days, and the mean time until CSP mass disappearance was 33.3 days. The mean hospitalization time was 10.5 days. The complications were mainly fever and pain, which were alleviated with symptomatic treatment. All 45 patients had recovered their normal menstruation at follow-up. CONCLUSION: Bilateral uterine artery chemoembolization with methotrexate appears to be a safe and effective treatment for CSP and causes less morbidity than current approaches.

Am J Obstet Gynecol. 2012 Jul;207(1):14-29. doi: 10.1016/j.ajog.2012.03.007. Epub 2012 Mar 10. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Timor-Tritsch IE, Monteagudo A. PMID: 22516620

...We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.

J Reprod Med. 2012 Jan-Feb;57(1-2):61-4. Late-first-trimester cesarean section scar ectopic pregnancy with placenta increta: a case report. Overcash RT, Khackician ZH. PMID: 22324271

...CASE: A 21-year-old, gravida 3 para 2 woman was diagnosed at 13.5 weeks' gestation by pelvic ultrasound and magnetic resonance imaging with a cesarean scar ectopic pregnancy and placenta increta. Surgical removal of the pregnancy via exploratory laparatomy with intraoperative use of vasopressin minimized initial blood loss. However, extraction of the placenta increta resulted in uncontrolled bleeding, requiring a supracervical hysterectomy. CONCLUSION: This is the first case report, to our knowledge, of a late-first-trimester cesarean section scar ectopic pregnancy with placenta increta. Early identification of the ectopic pregnancy may allow for more conservative, nonsurgical management. However, with a more advanced gestational age and placenta increta, surgical management is most appropriate to minimize associated maternal risks. A transverse wedge resection of the implantation site, uterine artery embolization, uterine artery ligation, endovascular balloon catheters, or uterine artery tourniquet may help decrease bleeding during surgical extraction of the pregnancy and placenta increta, and also may prevent a hysterectomy.

Reproductive Outcomes After Cesarean Scar Pregnancy

Hum Reprod. 2007 Jul;22(7):2012-5. Epub 2007 Apr 20. Reproductive outcomes of women with a previous history of Caesarean scar ectopic pregnancies. Ben Nagi J, Helmy S, Ofili-Yebovi D, Yazbek J, Sawyer E, Jurkovic D. PMID: 17449510

...METHODS: The study included those women who received treatment for their Caesarean scar pregnancies between April 1999 and October 2005. Their ability to conceive, the time it took to become pregnant and outcomes of subsequent pregnancies were all recorded. RESULTS: 40 women with Caesarean scar pregnancies were managed in our unit. The uterus was conserved in 38/40 cases. Follow-up data were available in 29/38 (76%) of women. Twenty-four out of 29 (83%) attempted to become pregnant. Twenty-one out of 24 [88%, 95% confidence interval (CI): 75-100] women conceived spontaneously. Twenty out of 21 (95%, 95% CI: 86-100) pregnancies were intrauterine and one woman (5%, 95% CI: 0-14) had a recurrent scar ectopic. Thirteen out of 20 (65%, 95% CI: 44-86) intrauterine pregnancies appeared normal. Nine out of 13 (69%) were delivered by Caesarean section. Seven out of 20 (35%, 95% CI: 14-56) intrauterine pregnancies ended in spontaneous abortions. CONCLUSIONS: Our study shows that reproductive outcomes following treatment of caesarean scar ectopic pregnancies are favourable. The risk of complications including recurrent scar implantation appears to be low.

Obstet Gynecol. 2008 Feb;111(2 Pt 2):541-5. doi:10.1097/01.AOG.0000287295.39149.bd. Recurrent ectopic pregnancy in a cesarean scar. Holland MG, Bienstock JL. PMID: 18239016

BACKGROUND: Ectopic pregnancy in a cesarean scar is a rare but well-recognized potential complication of cesarean delivery. Multiple risk factors exist, including prior uterine surgery, a history of uterine infections such as endomyometritis, and a brief interval between uterine surgery and subsequent conception...CASE: This patient presented for a dating ultrasound examination at 4 6/7 weeks of gestation. Her history was significant for an ectopic pregnancy in her cesarean scar 3 years prior that was managed by surgical resection. The initial ultrasound examination was suspicious for a recurrent ectopic pregnancy in her cesarean scar. The diagnosis was confirmed on repeat ultrasonography at 6 weeks of gestation. She was treated with methotrexate, and the pregnancy resolved without complication. CONCLUSION: Ectopic pregnancy in a cesarean scar is an important diagnosis to consider in a woman who has had a history of cesarean delivery and whose early ultrasonography shows a thin, lower uterine segment or a low implantation site. If the diagnosis is not clear on initial ultrasound examination, the patient should be followed up with serial ultrasound examinations. Once recognized, patients with this complication may be treated either surgically or medically as indicated by the clinical situation.

In The News

2013-06-18T13:02:24-07:00

The AMA has endorsed the idea that “obesity” is a disease, not a “condition”. (Personally I consider it a characteristic.) Forbes states that this is “a move member physicians hope will spur better reimbursement for treating overweight Americans and create better health outcomes.” Exactly how it’s supposed to “create better health outcomes” when commonly prescribed treatments do not work long-term or create good health outcomes is not addressed.

In good things, Shakesville’s Fatsronauts 101 series continues to hit it out of the park.

The NY Times does a piece on Melissa McCarthy that doesn’t focus on her weight. That’s allowed?

The NY Times also reminds people go get some sleep.

Filed under: Anti-Obesity Programs, fat acceptance, FatnessInGeneral, News, Sleep

Don’t Know What To Wear? Check Out Pose Daily Fashion Forecast!

2013-06-18T09:44:20-07:00

Be Social!

Hi Friends!

Yes I know I have been MIA for the last two weeks. It’s summer and the Idaho mountains were calling name, so I had to take a little vacation time and work on my soul. But now I’m back and ready to rock n roll! Apparently i’m in to rhyming today…

Even girls with a passion for fashion, and closet as full as mine, can still be plagued by the same problem as millions of other women, and that problem is deciding what to wear. We have all been there, standing in our underwear, hair and makeup ready pulling item after to item out of our closet and trying them on only to moments later take them off in frustration and start the whole process over again. Whether the problem is an essential piece we can’t seem to find, a hamper full your favorite clothes that hasn’t made it the washing machine yet, or even the ever changing weather, getting dressed is a difficult task that can set the tone for your whole day. I know for me if I am running late after a million wardrobe changes, unhappy with my final look, or inappropriately dressed for the season, temperature or trends, I can easily turn my typically positive outlook into a grouchy, sloppy mess of overall yuck, and that is sooooo not pleasant for anyone.

While I may not have a solution to all wardrobe problems I have found a resource that serves as a tool to help make outfit choices based on your local weather, popular trends and lifestyle. One of my favorite websites and apps for fashion, Pose, has created a new feature Fashion Forecast! With the Fashion Forecast daily email Pose is curing closet paralysis like never before by generating a daily outfit recommendation, tailored to fit the weather conditions in your area, just for you. I signed up for my personal Fashion Forecast a couple weeks back and have been taking it for a spin, and I am honestly pretty pleased with this feature. In the morning I simply check my email on my phone and at my finger tips I have the weather report for the day, photos of some great looks from other Pose members (INCLUDING PLUS SIZED MEMBERS) and some tips for creating the perfect looks for casual and dressed up options. Pretty groovy huh?

The Pose Fashion Forecast Feature, and Pose in general is completely free to use and is a great resource for exploring fashion and style whether you are searching for the perfect outfit idea, or even to share your looks with others. What have you got to lose? CLICK HERE to sign up for your own Daily Fashion Forecast and make your mornings a bit easier! Oh and while you are at it make sure to follow me on Pose so we can connect!

xoxo

Stiletto

Be Social!

My first column for DIVA magazine is out!

2013-06-18T10:02:35-07:00

My first Seeing Queerly column for DIVA magazine is out! You can get it in all the usual magazine stockists, and directly via the DIVA website.

This month I'm talking about the weird world of the obesity expert, and how it differs from my queer world o' fat.

By the way, I'm an experienced and versatile freelance journalist and available for commissions.

Proudface, hehe.

You don’t owe life pretty

2013-06-18T09:19:29-07:00

On the Body Acceptance subreddit, we often get posts proclaiming that the poster is simply ugly. Sometimes they even post photos as proof and, to be honest, it’s almost always people who are conventionally attractive. And they get plenty of replies telling them so. I never reply with “oh you’re beautiful” or “there’s no such thing as ugly.” While these are popular replies and I know they have every good intention in the world, I’m not so sure they’re helpful. Because, here’s the thing. Life may often be treated like a beauty contest, but that’s the wrong way to look at life. You don’t owe beauty to anyone — not anyone.

This definitely applies to fat people, as we are very often seen as conventionally unattractive because of our fat. But we don’t owe anyone thinness — not a single person. Not our doctors, not our friends, not our family, not our loved ones, not even ourselves. What we do owe ourselves is self-acceptance and love and a path to taking care of our bodies if we so choose to do so.

Now, I hope as much as anyone else that one day our standards of beauty disappear completely. That every single person is seen as a unique and beautiful person because variety is so fucking awesome it’s unbelievable. I hope that fat people can be seen as beautiful, I hope that conventionally unattractive people can be seen as beautiful and I hope that everyone can appreciate the beauty that is difference. Mostly I think this will happen when we start learning to look at people, especially women, without objectifying or sexualizing them.

Let’s face it, conventionally unattractive men are seen everywhere on the arm of conventionally attractive women (several TV shows, movies, and cartoons come to mind). Whether or not we see these guys as gorgeous, we do see them as complex human beings with their own bodily autonomy and the ability to succeed, find happiness and love, have friends, have sex, etc., regardless of how they look. Women? Less so. Almost everything about women is contingent on their appearance.

I believe that the objectification and over-sexualization of women plays a large part in life’s little beauty contest. After all, thin women get paid more than fat women (the same does not hold true for men). And hey, what about the multi-billion dollar beauty industry intent on selling us creams and makeup and weight loss products and eye lash lengtheners and hair removal products and all of the things that tell us we’re not smooth enough, we’re not thin enough, we’re not young enough, we’re not pretty enough, we’re not good enough.

My point is that until we do see an end to beauty standards completely and view people as individual, whole people, you don’t owe life pretty. You don’t owe anyone or anything beauty. Feel free to be ugly! Let that ugly flag fly because ugly people still find love, happiness, have friends, families and children, successful careers, etc. Ugly makes life harder, it’s true (although, again, I haven’t yet seen one of these people post who was conventionally ugly), but not because there’s anything wrong with being ugly. It’s because people are assholes.

It’s the same thing I argue for fat people. Yes, being fat is hard and almost every fat person wants to be thin, but not because being fat is so horrible. It’s because being fat in a world that idealizes thin is horrible, because people are horrible, because our culture of fat hate and discrimination and oppression is horrible. But fat? Ugly? No, it’s not bad. By itself, our looks don’t make life hard or hopeless. As soon as I learned that there was nothing wrong with me as a fat person and, hey, maybe not even that attractive according to a lot of people, my life got easier (I also stopped judging other people). Remember, it’s not you, it’s them. It’s our culture. It’s misogyny, looksism, fatphobia, ageism, ableism, racism and a dozen other things, but it’s not you.

Life is not a beauty contest. And you don’t owe life pretty.

Filed under: DW, Terrible Tuesday

An exercise

2013-06-18T07:33:44-07:00

Just as a change of pace, try the following. Take an article about the “obesity epidemic,” and substitute the word “sexiness” for “obesity.” Does that improve the article? Make it fun? Make it silly?

I tried it myself, and it really helped, up until the phrase “sexiness-related diabetes.” :(

First, Feed Thyself!

2013-06-18T05:00:29-07:00

(Trigger Warning: Food issues)

When I am not feeling like myself, as was the case yesterday (and really the day before as well), I have found that I also don’t treat myself as kindly as I should or would like to. I tend to let a lot of things slide. Specifically, eating food. Mind you, I’ll almost always manage to get some coffee/caffeine in me, but only to stave off the inevitable headache. Yes, I did not eat until 7:30 pm yesterday and of this I am ashamed. I know better. I had food in the house. I just wasn’t feeling well, and obviously not thinking straight either.

I recall the long ago days when I was 19 and 20 years old living on little more than Taco Bell, Lean Cuisine and Jose Cuervo. Blegh! I could never do that to myself again. I know I was so depressed and truly suffering through the worst of my PTSD at the time (though I hadn’t a clue then) but I also didn’t really know how to eat or care for myself, either. How could I? I know at one point my grandma was worried about me and would pack me lunches for work, even though I lived and worked twenty miles away. Gawd how I miss her. Not because of the lunches, mind you, but her caring and loving and sense of humor and hugs most of all.

It is when I am not taking care of myself that I am truly letting myself, and those I care about, down. My grandma would scold me for not eating all day like I did yesterday. I can picture the face she’d give me and then I know she’d dash into the kitchen and rustle up some combination of simple, filling and awesome. When my family had so little, we always had Sunday dinner at grandma’s house. I looked forward to it all week! My favorite was the simple little green salad she’d serve before the main course. I didn’t even know what courses were back then, but I knew salad was so special and rare and my favorite!

I suppose growing up in a food insecure household meant that continuing food issues would be inevitable. I hadn’t realized just how much of our childhoods affected us as adults, on this topic specifically, until two weeks ago when I literally had nothing to eat in the house and relied on B for dinner one evening and felt like utter shit for it. He made no bones about it, of course, but how I felt was so triggering and awful that the next morning I went to the grocery store and spent $100 on groceries just to be able to breathe again. *Sigh*

I think I have used not eating as a way of feeling as though I am in control of something in my life when so much is truly out of my control. Like this one thing? I got this! Ugh! This is not who I am or want to be. I have worked very hard to break these patterns and behaviors. So why does it pop back up so suddenly now? Really things are going great for the most part. I just need a job! That’s it! So simple, three letters, all the difference in the fucking universe! I would have at least some relief if I knew whether I’d be getting unemployment money coming or not. I should be getting the word any day now, but it’s killing me! I just need to know so I can find another means of paying my rent in time if need be. I don’t know how I’ll do that, but I’m sure I’ll hustle something up somehow.

I also felt like a big phony faker on Sunday night and I hated myself for it. I went to my BFF’s birthday dinner and felt lousy and truly didn’t want to be there. My boyfriend (OMZ! I cannot believe I have a boyfriend! Ha-ha!) was supposed to go with me, but had work stuff to tend to. It was nice to drive up with “Q” but I think even she could tell I wasn’t the usual me. I did my best not to show how yucky I was feeling, but inside I just wanted to run the fuck away and hide under the covers. But I missed Steph so much and so rarely get to see her and if I’d bailed this time I knew she’d hunt me down and kill me! Ha-ha! It wasn’t that I had a horrible time or anything, but I did have to sort of grin and bare it through the evening. I felt like an alien, to be honest. I felt like I was surrounded by all of these smart and put together people with cool jobs and awesome lives and adult problems and here I am barely able to hold it together. Ugh!

Today is a new day and I shall treat it as such. I know how to care for myself, certainly better than the last few days. I will be more mindful of how I am feeling and listen carefully to what my body needs. I distinctly recall three times yesterday where I heard my stomach growling and rather than paying attention and providing food/fuel for my body and brain I actually thought to myself, “Ugh! Why are you growling? Shut up!” Whoa! NOT ME! I guess I just needed some comforting and didn’t know how or who to ask for it. I mean, I don’t think anyone else even knew or could know at the time that I needed such a thing, maybe I didn’t even know. I know now. But I also know that I wasn’t doing much to comfort myself.

Self care takes many forms. First and foremost should be the basics like food and water. I have not struggled with that part in so long I guess I actually forgot for a bit there just how that felt and can spiral into worse. I am glad that I was able to recognize it before it got out of hand. I know that I used to starve myself rather than ask to borrow a dollar from a single soul back in those Lean Cuisine and Tequila days. Older and wiser, eh? Ha-ha! Okay, I can do this. I will do this…there is no try, only do!

the HAES® files: Finding the Compassion in our Peace Movement

2013-06-18T03:00:12-07:00

by Jenny Copeland, PsyD

As a size acceptance advocate – and mental health professional – defensiveness is no stranger to me. Human beings naturally resist that which is unknown or uncomfortable to them. For many of my HAES® colleagues, I am certain we can comfortably say we are met with strong resistance when introducing our principles to other professionals and when encouraging patients to step away from the scale. But it is not the resounding “NO!” I am concerned with today. It is the defensiveness.

The dictionary defines defensiveness as being “excessively concerned with guarding against the real or imagined threat of criticism, injury to one’s ego, or exposure of one’s shortcomings.” Sigmund Freud would describe it as an unconscious manner of protecting the ego – the conscious self. While resistance might imply keeping something at arm’s length, defensiveness implies a certain amount of fighting back. As a community, we as size acceptance advocates often note the extensive and elaborate ways in which the ‘opposition’ defends their viewpoint. As a community we are not immune to this. We become defensive toward others in our own community with different perceptions, different actions, different motivations. We defend the legitimacy of our suffering against others who have differently suffered. And in the action of defending our position, we breed conflict and divide our ranks.

Freud would call this “splitting,” a dichotomous style of thinking wherein we see things as black or white, all good or all bad. This ultimately produces an “us and them” mentality which generally weakens the size acceptance movement. What emerges are divisions of the privileged and the exploited, those learned and ignorant of the movement, those with an eating disorder and those without, and even the thin and the fat. As a community, we could argue whether one group’s experiences of weight or size stigma are more or less significant, or even more or less legitimate. What would be the point?

The Health At Every Size® approach has sometimes been called a peace movement, one of acceptance and reconciliation for the past wrongs we have inflicted on our bodies. At these times when we are split from within and have pushed each other away, I wonder where our peace is. Sometimes we fight so hard to have our voices heard that we silence others’ – sometimes even the voices of our fellow travelers in this journey.

Karen Armstrong, a pioneer in religious studies, put it this way: “Look into your own heart; discover what it is that gives you pain. And then refuse, under any circumstance whatsoever, to inflict that pain on anybody else.” How wonderfully simple. Recognize and acknowledge that which has hurt us, then refuse to pass that same hurt onto anyone else. Stop the bullying in its tracks. Armstrong founded The Compassion Charter with this in mind. Although its roots are in religious and moral diversity, I think the sentiment applies to size acceptance as well:

The principle of compassion lies at the heart of all religious, ethical and spiritual traditions, calling us always to treat all others as we wish to be treated ourselves. Compassion impels us to work tirelessly to alleviate the suffering of our fellow creatures, to dethrone ourselves from the centre of our world and put another there, and to honour the inviolable sanctity of every single human being, treating everybody, without exception, with absolute justice, equity and respect.

It is also necessary in both public and private life to refrain consistently and empathically from inflicting pain. To act or speak violently out of spite, chauvinism, or self-interest, to impoverish, exploit or deny basic rights to anybody, and to incite hatred by denigrating others—even our enemies—is a denial of our common humanity. We acknowledge that we have failed to live compassionately and that some have even increased the sum of human misery in the name of religion.

In its simplest form, The Compassion Charter is a resurgence of the Golden Rule: Do unto others as you would have done unto you. It is a value taught to many in their childhood, hopefully working to build regard and empathy for others. The question is, how does this apply to the size acceptance movement? There are different schools of thought for advocacy, whether we should take a ‘straight and narrow’ approach where we hold strongly to our ideals and refuse to compromise them in any shape or form. Others find value in the grey areas, working to reach those outside the community and gradually bring them into the fold. This is a debate for another time.

My question, then, is how do we best foster compassion for one another? How do we nurture our community and build relationships while still challenging each other to grow? I don’t think we accomplish this by saying some have suffered more or less at the hands of size hatred. I don’t think we accomplish this by saying the Health At Every Size approach is valid for some sizes but not for others. I think we can accomplish this by less defensiveness with one another. This would imply listening more often than we talk and finding space for every person in our movement – no matter what size, shape, gender, sexual orientation, race or ethnicity, socioeconomic status, level of privilege, age, ability level, knowledge level, and many other characteristics people may have. I think this happens through embracing the diversity within our ranks, recognizing each person’s unique experience as just that – unlike what we have personally encountered, but of equal value and legitimacy.

What do you think?

Tagged: community, compassion, compassion charter, defensiveness, diversity, golden rule, HAES, health, Health At Every Size, karen armstrong, peace movement, size acceptance, size hatred

We’re Gonna Need More Wars

2013-06-18T01:38:16-07:00

There is an argument that suggests that it’s ok to body police, bully, shame, stigmatize and have a war against obese people because being fat is an indication that someone doesn’t prioritize their health and that costs taxpayer dollars, and so prioritizing health is a social obligation and the punishment for not holding up our end of the bargain is that the government has declared war on us.

For today let’s set aside the fact that body size is not an indication of behaviors, health, or prioritization of health. Even if it were true that fat people don’t prioritize our health, the argument is still bullshit – a convenient lie used to justify indefensible bigotry. The way I know that is that if people truly believed the argument, there would be a lot more wars:

The War on Football Players: Football players, especially at the professional level, are absolutely not prioritizing their health. When their careers end their bodies are often in horrible shape – multiple concussions, blown knees, some players admit to having had over 50 surgeries after leaving the NFL. They retire at an average age of 28 years old with no salary, studies show that 78% go bankrupt within 5 years of retirement, but they don’t get insurance until they turn 50 and then only if they are vested and qualified. This sounds expensive, let’s get that war going.

The War on Insomniacs: Lack of sleep has been shown to be detrimental to people’s health. Studies suggest that most people are shown to need 7-8 hours of sleep a night. Sounds like we’re gonna need to gear up for a war on people who choose to sleep less than what is shown to be healthy.

The War on Rock Stars: The rock star life that we celebrate as a culture includes drugs, alcohol, and a schedule of, rehearsals, shows, and appearances that runs performers ragged. These people are clearly not prioritizing their health. Where’s the war?

The War on Unhealthy Thin People: This whole idea rests on stereotypes about fat people – that you can tell by a fat body that someone doesn’t eat well and doesn’t exercise enough. Of course that’s no more true then the idea that every thin person eats well and exercises. Everyone knows a thin person who eats a ton of “junk food” never exercises and remains thin. If we’re going to do this we’re going to need to have a war on those people too.

The potential list goes on – UFC fighters brag about not prioritizing their health, professional bullriders, X Games athletes, people who choose to work third shift, people who choose jobs with repetitive motion, people who climb mountains, Iron Man triathletes, people who don’t look both ways before they cross the street, people who buy cars that don’t have the highest safety ratings etc.

The truth is that there are many ways to prioritize and de-prioritize our health and none of them can be be judged by body size. People of all sizes prioritize their health at different levels for different reasons. Fat people simply make good scapegoats because we share a single physical characteristic that is easily picked out in a crowd. The prejudice is kept in place by “everybody knows” thinking, the frantic shouting down of good research, embarrassingly poor research done from a platform of confirmation bias or for profit, and lies about healthcare costs.

In what should be a blinding flash of the obvious (with a nod to my friend Stan), the solution is not to have more wars on more people. The solution is to end the wars.

I don’t believe that health is a moral, social, or personal obligation (you can choose to prioritize things other than your health just like professional bull riders, X Games participants, stressed-out sleepless executives, those who have elective plastic surgery, sky divers, and people who don’t look both ways before they cross the street). Also, let’s not kid ourselves – our health isn’t completely within our control. Health is multi-dimensional and includes genetics, access, stress, environment, and behaviors among other things.

It’s time to recognize that public health is not about making the individual’s health the public’s business. It’s about removing stress whenever possible (like, say, the stress of having the government fight a war against you or hearing politicians promise that in a generation they will have eradicated all the people who look like you) and providing information, access, and options to people of all sizes.

Those who disagree with that better be prepared to police EVERYBODY and fight a war on people who don’t prioritize their health on every imaginable front because it’s unacceptable to simply pick a group of people who can be identified by sight and start “calculating their cost” to support the idea of having a war to eradicate us.

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The Tankini

2013-06-17T17:23:57-07:00

So it’s getting on summer (Although it doesn’t feel that way in NYC), and blog posts will be shorter and there will be no blog posts on the following dates: 7/29, 8/5, 8/12, 8/26^th. Normally I might take a summer break but fat hatred doesn’t. If I don’t post those days it’s not because I had a combo heart attack, diabetes, MS, plane crash, global warming catastrophe, I’m going to be on vacation, enjoying good food and fun exercise.

Last Sunday was the Big Fat Flea (Formerly the Fat Girl’s Flea). My favorite fat positive annual event. (Love it to be a bi-annual event, hint, hint). This year I paid $25 to get in a half hour early. And for $53 I walked out with: 2 pairs of pants, an awesome torrid dress, a hippie shirt, beads for my niece, sunglasses, a bathing suit, a swimming shirt, and tankini top. (I now have more tops than bottoms.)

Recently I joined an outdoor pool and despite the weather have been swimming 2-4 times a week. Unlike the once a week I was doing at the pool from hell. This meant a bathing suit upgrade from the 3 regular and one emergency bathing suit (the emergency suit was fraying.)

So off I went to Marshalls which has been going downhill for a while. I don’t blame Marshalls for the fact that two piece bikinis vanish after size 12, or that thin women’s bathing suits look like string and fat women’s a full-on evening gowns but I do blame them for their lack of inventory. Once we get pass the fat ceiling of size 16, selection and quantity becomes horrendous. I understand that not all fat women want to wear tankini, bikini and some even like the skirts but we are 2/3 of the majority, why do we have to get crap. All they had in my size was a few one piece dresses. I found one bathing suit, saw the long line and figured I might do better at Sears next door.

I did. Even though I call Sears the store of the most returns. If Sears didn’t have a better selection of bathing suits, I would tell them to stick to appliances.

Sears had tankinis, one pieces and skirts. But the tankini bottom and tops were sold separately and even with a half-off sale the pieces were $25 double than what the were in Marshalls. I ended up buying $125 worth of bathing suits. I'm not against spending more to get good quality, but I had a feeling that in one or two years I would be replacing them.

I thought about waiting for the flea to get my bathing suit but the one thing the flea doesn't have is quality control. It is all based on donations.

Doesn't mean I'm disappointed. I never am. I always find a great piece (This year being the Torrid dress) At the flea I got a bathing suit, a top and a swim shirt for $15. Two of them were from a sample sale and never worn. I also feel like I'm a person at the flea because I know that the organizers are looking out for us. They want shoppers to go away with that one or more great article of clothing.

Friends & Fun

2013-06-17T17:18:44-07:00

I had a whirlwind of a weekend. I had two lovely friends celebrating birthdays and wanted to do all I could to make sure they had a great one. I had no idea what was in store for me, but apparently I was game for anything. Ha-ha! I had a job interview and a quickie photo shoot on Friday. Both went splendidly, then I headed up to visit the lovely Laura in Northern California. She always treats me like royalty and I wanted her to feel as special as she always makes me feel.

We ate, we drank and we watched Casablanca. Okay, I watched Casablanca. Poor Laura was pooped and fell asleep a third of the way in. Ha-ha! We slept in and ate a wonderful breakfast from Black Bear Cafe and tried to make our big plans for Saturday night. Again, I had no idea what we would be doing, but I was ready for a good time! We talked about what she wanted to do but ultimately, we ended up going to a BBW club I said I would never return to (or support) again. What can I say, she’s a fantastic friend, it was her birthday and she literally begged me to go (and paid for me to as well). I couldn’t say no. (And for the record I loathe begging, but it was a special and sweet case.)

When the hotel turned out to be booked up for someone’s big 40th anniversary party I offered for these two lovely ladies to stay at my house if we got a cab to and from the club. I won’t lie, I was not looking forward to going, but I was happy to be in such good company and the cocktails sure helped! Ha! We primped and prepped at my place and laughed and drank and finally made it to the club around midnight (fashionably late?). I’d only just met Ashley that morning, but she and I soon became fast friends. As Laura was chatting and being the social butterfly that she is Ashley and I grabbed drinks and hit the dance floor. Well, the music sucked (as always, for real! Transitions aren’t that hard, yo! And let’s keep playing the same songs for life…NOT!) but there was a couple of gems and I got in one request in the end (though I asked the DJ myself I ended up having to get someone else to ask him again before it got played).

We got our dance on, our drinks on and Laura got some piercings on! Woooo! I won’t say what or where, but it was a piercing party and the birthday girl got treated to some bling. We closed the place down and shuffled our drunk asses outside. I was wearing this Eshakti dress in Red with a black petticoat from ChicStar.com underneath. I looked and felt like a doll! I love that dress and it was only the second time I’d worn it. While we were outside waiting for our taxi I suddenly felt the urge to lean and quickly found a little post to lean on. Then it was apparent that I wasn’t moving anytime soon, worse than that, it was all about to go downhill from there.

These two girls, my lovely friends, were so kind and sweet and caring and loving. I cannot sing their praises enough! They tried to get me to walk or drink water but I knew it was too late, I very quickly and pointedly threw up in the bushes. Luckily the sprinklers turned on literally the moment I puked the first time. It was kind of perfect! In the cab Ashley kept me steady and sane and breathing and lectured the driver on what “easy” means. Ha-ha! Had to pull over twice, sadly, but we made it back to mine in one piece, unscathed.

I do not know how I got so drunk, I didn’t think I’d had very much, but we were celebrating and I haven’t had much more than wine in quite awhile. And I broke my own 1/1 water/alcohol rule. Boo! I managed to not ruin or mess my dress and apparently was quite lady like throughout the entire thing. Sadly, I did throw up for hours, but I also woke up not feeling like death warmed over and for that I am eternally grateful to Laura & Ashley. Those troopers really took care of me. We all had a great time and that was what it was all about.

Sunday afternoon I got to spend some time with my favorite guy and see his apartment for the first time. Oh that boy! He turns my brains to goo, I tell ya! In my hilariously drunken state the night before, I’d come up with the perfect “move” for every scenario, if you know what I mean, but when I was in the moment, I was too tired and too chickenshit to do anything. Ha-ha! Just as well, probably. It was so lovely just to see him and hang out and stuff.

Then I had to dash off to my BFF Stephy’s b-day dinner with my other BFF “Q”. It was nice, but my stomach was not feeling good so I took it slow and made the most of it. It was super great to see Steph and her guy and just chat and chill. Haven’t done that in ages. Some quality time with her kitty Rocky was a delightful surprise, too. We all love that little guy, but he’s been very sick for quite awhile and we’re all worried about him. Got home around midnight and pretty much just crashed.

Today has been mellow…on purpose. I just need to like not do things today, ya know? I did take care of a DMV thing and applied to jobs and stuff, so I’m not completely irresponsible. But I’m still super tired and just need to take it easy and reset, so to speak. In the end it was a great time pretty much all weekend (except for those few hours of vomiting, Ha!) and I got to see so many people that I love dearly. All worth it, I’d say. Happy to be alive and well and live another day, that is for sure.

<3
S

Adipositivity 610: ANNIVERSARY MESSAGE from Substantia Jones

2013-06-16T17:00:00-07:00

AN ANNIVERSARY MESSAGE FROM SUBSTANTIA JONES What a week last week was. The Huffington Post, Bust Magazine, The Daily Mail, several other outlets, and a couplefew interviews for pending articles. All this attention not only blew sunshine up my skirt, but also resulted in gobloads of mail, much of it from folks for whom the concept of resistance against body shame is new. I find that exciting and energizing. Outreach overdrive! Also last week: The Adipositivity site was hacked and two years worth of photographs were removed from view. I was threatened with a team of lawyers, suspended from tumblr, and informed by my web host (honestly lovely people) that I need to rebuild the site elsewhere by June of next year. I was called a “fat piece of shit” on Facebook by a dude in a non-ironic trucker hat with a cover photo filled with rows and rows of beer cans. (I think he's single, Ladies!) God only knows what they’re calling me in the comments sections of the above media pieces. Aaaand my rickety old computer began taking its last few gasps. Yes, the computer where all the naked fat ladies live. With the positive attention comes the negative. I'm cool with that. But I think I had a headache for seven days straight. While going through each of the 600ish Adipositivity images to remove hacker code, I was reminded of the way things were when I started the project in ’07. Laurie Toby Edison's “Women En Large” was on many a fatty bookshelf, but Leonard Nimoy’s book didn’t yet exist. Nuded-up fatfolk on the internet? Rare. For the purposes of uplift and empowerment? Rarer still. The Fatosphere was new enough for me never to have heard of it. My idea of fat activism began and ended with Marilyn Wann and NAAFA. That was it. Look at it today. Not only can I not keep up with all that's written and produced, there are activism efforts of which I’m not even aware. This is delicious stuff. This is progress. Many more battles to wage, but I’m committed to hanging in there with the rest of you as long as I can. Hey, I tattooed my ass, didn’t I? (Answer: No.) Thanks, as always, for your interest in the project. And thank you, Adiposers, for six years of dropping trou for my camera. I’d better stop here, before I start using words like ‘journey.’ If you’d care to give to the Adipositivity Computer & Aspirin Fund, you may do so by dusting off the old 'donate' button down on the left. Your contribution will be smiled at, then put to adipositive use. In that order. ~Substantia Jones Adipose: Of or relating to fat. Positivity: Characterized by or displaying acceptance or affirmation. MISSION: The Adipositivity Project aims to promote size acceptance, not by listing the merits of big people, or detailing examples of excellence (these things are easily seen all around us), but rather, through a visual display of fat physicality. The sort that's normally unseen. The hope is to widen definitions of physical beauty. Literally. The photographs here are sometimes close details of the fat female form, often without the inclusion of faces. One reason for this is to coax observers into imagining they're looking at the fat women in their own lives, ideally then accepting them as having aesthetic appeal which, for better or worse, often translates into more complete forms of acceptance. The women you see in these images are educators, executives, mothers, musicians, professionals, performers, artists, activists, clerks, and writers. They are perhaps even the women you've clucked at on the subway, rolled your eyes at in the market, or joked about with your friends. This is what they look like with their clothes off. Some are showing you their bodies proudly. Others timidly. And some quite reluctantly. But they all share a determination in altering commonly accepted notions of a narrow and specific beauty ideal. Bookmark adipositivity.com and check back often, as new photographs are added regularly(ish). And please help spread the message. The Adipositivity Project: Changing attitudes about the aesthetic validity of big women, one fat fanny at a time. ABOUT THE PHOTOGRAPHER: Substantia Jones’ photography has been exhibited in galleries and museums throughout the US East Coast, and has appeared in The New York Times, Time Out New York, and some other publications she can’t recall at this time, but you probably haven’t heard of them anyway. She is biographied in the 2006 Who’s Who in America (though under the name her momma gave her), and back in the day, she won some photography awards which would sound somewhat Mayberry if listed here, but at the time, they damn near made her cry. Still kinda do. She lives in Manhattan, where she also sometimes steps out (more like lays around) in front of the camera, and on some of those occasions, the snapping is done by her trusty sidekick, Dr. H, who also fetches her banana popsicles and maintains her muse, a certain pancake colored dog who’s asked that his name not be mentioned on the Internet. Ms. Jones likes crispy calamari, Squidbillies, and the ika okonomiyaki from Otafuku in the East Village, if only the lines weren’t so long. Thou shalt not reproduce without permission. Except for babies. Make all o' them you want. © The Adipositivity Project 2007-2013

Hate Your Body? Take More Pics!

2013-06-17T08:05:21-07:00

My friends may have regretted letting me play their “reindeer games.”

I used to really avoid being in photos.

Until relatively recently, that was pretty easy to do. Before every cell phone had a built in camera, before selfies and instagram (follow me!), you could really get away with avoiding photos. Only photography nerds (like me) used to carry around cameras, and it was mostly for capturing the raw beauty of a dead pigeon on Avenue A.

Sometimes the fact that everything gets photographed or video-ed really bugs me. (I can’t be the only one who’s been at a concert and wanted to say to the tall dude in front of me, “Hey, how about putting your camera down and just watching the show right now?”)

And yet, I also see it as an interesting opportunity to reclaim your self image. If you sort of go with it, you can actually use things like selfies as a tool to improve your body image.

How To Improve Your Body Image With Photos

Action Step #1: Take Some Really Bad Photos Of Yourself On Purpose — Whip out your phone or camera, and take a ton of pics of yourself. I’m talking in the hundreds. Take them from weird angles. Make funny faces. You can do this with a friend too. You may even want to do this a couple of times over the course of a week or a month. Do not skip this step!

What This Does: When you take “bad” photos of yourself, you get used to your own image. You start to realize that “good” or “bad” pics are all about angles, lighting, expression and not really about you. (Remember, even when models are shot for print ads, hundreds of images are taken, then one is chosen and airbrushed to death.) When you do this process, you get less upset when someone else takes a less than flattering photo of you. You’ll be less triggered when you catch yourself reflected in a storefront. You may even have fun with your image for the first time.

Action Step #2: Take Some Selfies And Post Them — Now, try to take some “good” photos. Think about your “bad” photo experiment and avoid taking pictures from those weird angles. Give yourself time to play around with lighting, angles, makeup, etc. And then, post those pics! If you don’t want them to be public, use privacy settings so that only certain friends can see them. You’ll probably get a lot more positive comments than you expect.

What This Does: This does two things. First, it allows you to control your public image. You get to put out the world images of yourself that make you feel good. Second, you get positive feedback from friends who will cheer you on and, at the very least, “like” your image.

Click To Tweet This:
“Photos are about memories and experiences, not just how you look or what you weigh.”

Action Step #3: Join A Body-Positive, Photo-Sharing Community — There are so many great tumblrs of regular folks showing off fatshion, generally being body positive, outfits of the day (ootd’s), and just pics of themselves being fat and exciting. (And don’t forget about Fatshionable Apples!)

What This Does: Looking at tumblrs like this normalizes bodies that you don’t normally see in everyday media. It’s a wonderful counterbalance to the very thin images you see every day. And you get a wonderful sense of community by looking at and responding to posters’ images. You may find it empowering to submit your own images too.

Don’t Forget This Mindset Shift
Photos are about memories and experiences, not just how you look or what you weigh. When you look at your photos, don’t just scrutinize your face and body. Think about what you were doing, who you were with, what was going on in the moment.

When you’re more willing to join in pictures, not only do you get an opportunity to preserve a memory, but your friends and loved ones get that too. They want you in their pictures. You’re part of that memory. Let yourself jump in and say a big, cheesy, “Cheese!”

FYI: The Summer Of Body Love Starts TODAY! This is your last chance to get in on it from the beginning. Go here to check it out
→ http://everydayfeminism.com/summer-of-body-love/

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Golda is a certified holistic health counselor and founder of Body Love Wellness, a program designed for plus-sized women who are fed up with dieting and want support to stop obsessing about food and weight. To learn more about Golda and her work, click here.

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Hate Your Body? Take *More* Pics! originally appeared on Body Love Wellness (http://www.bodylovewellness.com) on June 17, 2013.

Fat, zazzly, and accomplished #truth

2013-06-17T07:52:20-07:00

A couple of weeks ago, a University of New Mexico professor named Geoffrey Miller tweeted a highly-offensive message about fat people who had the gall to think they would be dedicated enough to complete a PhD, implying that they shouldn’t even waste everyone’s time by bothering to apply in the first place. The tweet went viral — although I wonder whether the initial transmission was due to people who thought it was funny and passed it on. But eventually, people who used their brains to get their PhDs rather than to warm their assholes caught on, and there was a huge backlash.

One of the responses to the affair came from Cat Pausé, a fat activist and Fat Studies scholar in New Zealand. She had the idea of compiling an “open letter” of fat folks who were studying for, or had completed, a graduate degree. The project was called “Fuck yeah! Fat PhDs.” I was awarded my Master’s earlier this year, and am currently enrolled in a doctoral programme, so I definitely wanted to be a part of it. I just needed a photo.

Let me tell you a little story. A year or so ago I attended a workshop on body image. It was filled mostly by psychologists, therapists, and counselors with an interest in eating disorders. A few had come with colleagues, but most of us didn’t know each other. We were asked to get a piece of paper and write down our three favourite parts of our bodies, our three least favourite parts, the three parts we were most ashamed of and, finally, who in the room we would show that piece of paper to and why. I didn’t find the exercise difficult. I could readily scrawl down (1) smile, eyes, boobs; (2) backs of my arms, ankles, tummy; and (3) back fat, knee fat, tummy overhang. The telling part was number (4): Anyone — because it does not define me.

Since I discovered Size Acceptance, I have to say that there are a lot more photos of me than there have been in recent years. Whereas once I used to scamper for cover at the first sight of a camera lens, these days it doesn’t bother me that much. That’s not to say I always like the photographs, but, eh, whatever. I sometimes look back at other photos taken over the years. Some that I remember hating so much that I wanted to cry and never leave the house again, I look at now and think, Hey, they’re not that bad. Some are even quite nice. Some are still awful. But I’m not renowned for photographing well and I no longer let it define my self-worth if a camera has failed to capture just how special a moment was.

This is the picture I chose

But back to the Fat PhDs. I don’t have any graduation pics because I hate all that stuff and didn’t go to any of the ceremonies. But as a result of my new non-terror of cameras, I had a selection of recent photos to choose from. I spent a week in London a few months ago for a cousin’s wedding and there were a few pre-event shindigs that let me get my glad rags out. The photo quality isn’t great, but most of them are of me and hubby looking happy and spruced up. We polish up well. But as I was flicking through the photos to choose which one to submit, I found myself trying to choose the one I looked fattest in. Seriously. I didn’t decide to do that up front, but I suddenly realized that that was what I was doing.

And then it hit me: two years ago I wouldn’t be caught dead on the business end of a camera, and if a photo of me did emerge that I hadn’t managed to shred, delete, or burn, then putting it up on the internet for the world to see would not be high on my list of things to do with it. And here I was, two years into Size Acceptance, willfully picking a photograph that showed me to look fat (although, admittedly, also quite zazzly) to add to this official “Up Yours, Dr. Miller” gesture.

If any of you out there are thinking “OMG, I could never do that, I will never learn to love this body,” I have to say to you that I am not one of those Size Acceptance folks who has learned to revel in every roll of fat and believe that my body is a thing of beauty. I wish I were. Perhaps one day I will be, but I’m not there yet. What is different now for me is that the idea that my body is not a magnificent testament to womanly loveliness no longer makes me want to curl up in a corner and protect the world from my hideousness and shame.

And now I look at that open letter from Cat Pausé, with page after page after page of Fat PhDs, and actually find myself incredibly empowered by it. If I weren’t already studying for my own doctorate, I’d probably want to go out and start one. Several people have said the same thing. I found myself smiling as I scrolled through page after page of fat men and women who had gone the distance and gotten their graduate degrees. I felt a sense of warmth and pride welling up in me, even though I didn’t even know most of them. For what? For academics? No. I think what I was experiencing was the virgin glow of seeing dozens and dozens of happy, accomplished, positive images of fat people. My response, and others, to this visual testament of fat success just goes to show how devoid of such positive reinforcement our normal visual diet is. I’m proud to be a small part in that change, but damn, we need more of it. Fuck Yeah!

If you would like to submit your photo to the “Fuck yeah! Fat PhDs” project, just click here.

Filed under: DW, Manic Monday

New dangerous body image message from UK department store

2013-06-17T07:38:53-07:00

A disturbing new trend is on the rise in high street fashion. In the past, retailers have been rightfully criticised for using ‘size 0′ mannequins and promoting an unrealistic standard of beauty, likely to be emulated by impressionable young girls. The retailers have always argued that these representations are aspirational, and more importantly, clothes simply…

Hold the Concern Please

2013-06-17T06:31:44-07:00

I keep hearing people suggest that it’s their moral obligation to tell fat people that we need to lose weight, exercise more, or that if someone sees a fat child they need to say something to the caregiver. I’ve been part of any number of conversations where people who had no business or permission to talk to me about my weight or health (and let’s remember they are two separate things) did so.

First of all, we know that you can’t tell anything from someone’s body size other than what size their body is, and what prejudices you hold about that body. Even if these people’s assumptions about fat people were true, the behavior would still not be justified.

I often respond by saying, with finality,”I’m not taking unsolicited opinions about my health, thank you.” What I think in my head is more along the lines of No. No no no no no no no. No. First of all, how much of an idiot do you have to be to talk to me as if I’ve never heard that I should lose weight. Do you think I’ve never seen a TV commercial? Listened to the radio? Looked the hell around? Do you think I live under a very large rock? By my count I get about 386,170 messages a year that my body is wrong. I’ve been fat for at least 27 of my 36 years so that’s 10,426,590 times that I’ve been told that my body is wrong. If I was going to buy into that bullshit I would have done it already. So how about you trust me when I tell you that the 10,426,591st first time is NOT the charm.

I think that when someone feels this strong of a need to “save a fatty”, it’s often really much more about their own ego than the person they are supposedly so concerned about. Like an ambitious relief pitcher, they want to get credit for the save. I call this “Pulling a Jillian” as in Jillian Michaels, ego maniac from The Biggest Loser, who can’t stop talking about how she’s saving lives and she’s making people healthy, she’s doing this and she’s doing that blah blah blah. Newsflash Jillian, if you really cared about people we would be hearing a whole lot less about you.

I am a grown ass woman making choices. That is my right. Just like other people get to make choices for themselves. You can decide that your path to health is a raw foods diet, vegan, vegetarian, liquid diet, whatever. I don’t get to decide how you live, it’s not my business. I get to make choices for my body and you have no right to question those choices. (And if you’re even thinking about making a “but my tax dollars pay for fatties” argument, head over here.)

The bottom line here is very simple: This is not a tree and I am not a kitten so you can put your ladder away. Thank you.

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“It gets better” is not enough

2013-06-16T18:48:00-07:00

I am sure that the people who say “It gets better” mean well. I am sure that they want to keep children from killing themselves. But “it gets better” doesn’t help a kid who is being teased mercilessly by his/her peers. If you’re 14 years old, and all your classmates have turned on you, what good is it to hear that things will be better in a year or more? I heard that sort of crap a lot when I was a kid, and I don’t remember it helping me much.

When I was that kid being picked on, what I learned was that adults can’t help, mostly because they don’t know how. I don’t know how well that has advanced, but I suspect it hasn’t.

To those who say “it gets better,” I’m sorry for disparaging your message. It isn’t wrong, at least most of the time. I was rocked with three emotional crises over a short period of time, but two years after the first one, I was a lot better. High school was still a trial, but it was better than eighth grade, and I did manage to gather together a group of friends. But “it gets better” isn’t much to offer a kid who is hurting now. Why can’t we make it better for that kid now?

The only thing I know is that, more than anything in the world, I want to help that kid who had trouble dealing with the torment. It seems to me that school administrators could do more to make their schools emotionally safe places. But maybe they don’t know how.

Public Health Does Not Make Me Public Property

2013-06-15T20:57:28-07:00

If I had a dollar for every time someone emailed me with some form of “But.. but… HEALTH!!” message in response to my fat activism, I would be a very wealthy woman indeed. I’ve heard it all when it comes to people trying to use health, either private or public, as a stick to beat fat people over the head with. To me it just boils down to one thing… no matter what a person’s appearance, weight, shape, level of health or physical ability, every human being deserves to live their lives in dignity and peace, without fear of discrimination or vilification based on their appearance, size, shape, body or health/physical ability.

Of course, to the essentialists out there who want to claim that fat activists are somehow anti-health, the idea of EVERYBODY deserving the same rights regardless of their appearance or physical state-of-being gets them into a right lather of outrage. There is this attitude that “public health” must somehow trump basic human rights for some kind of greater good. Of course, this is borne of decade after decade of big pharma, the media and the “beauty” industry carefully constructing a culture that equates health with attractiveness and thinness, and manoevering those measures of health to unattainable levels that very, very few people in the world actually come close to meeting, ie thin, white, able-bodied, heterosexual, cis-gendered, affluent, etc.

Fat activism, even those of us who actively call out healthism, is not an anti-health message by any means. In fact, it is quite the opposite. I believe that everyone, yes EVERYONE, deserves access to the same healthful resources. Clean water. Clean air. Safe spaces to engage in physical activity that is enjoyable and inclusive. Abundant, fresh, affordable, nutritious food. Compassionate medical care. Vaccinations against communicable diseases. Fair pay and working conditions. Comprehensive education for all. Mental health care. Accessible public spaces for all bodies. Affordable housing. Affordable and suitable clothing. All of these things contribute to improving the general health and quality of life of all people.

What I do not support is the idea that public health renders some people’s bodies as public property. Public health is important in our society, and I am all for universal health care (an imperfect version of which we are lucky to have in Australia). I am all for public health ensuring that our water is clean, that everyone has access to the medication and treatment they need, that people are aware of the importance of vaccination, that all people are encouraged and enabled to get outside into a clean, safe environment and enjoy moving their bodies, that public funding goes into curing disease and providing those treatments to all human beings and so on.

What I do not support from public health is the marking of non-normative bodies as “diseased” or “defective”. I do not support the removal of agency and self-advocacy from people with non-normative bodies. I do not support intervention into our bodies and health by public health organisations. I do not support the vilification of human beings based on their appearance. I do not support public health being driven by the diet, beauty and pharmacy industries, or the mainstream media, all of which have financial gain to be made in the othering of people based on their appearance. I do not support public health campaigns that mark some bodies as inferior, immoral or defective. I do not support public health campaigns that encourage friends, family, schools or other groups to intervene in to other people’s health. None of these things actually help improve individual health or quality of life, in fact they all impact both health and quality of life negatively.

Anything that renders human beings as vulnerable to any of the above is public shaming and public stigmatisation, not public health.

Part of living in a society is that we can all contribute to that society for the general betterment of all. Some people will need different resources and levels of care to others, because like any other living species, human beings are diverse. That does not make those people beholden to society in general to try to change themselves to meet the narrow band of “average” that is classed as “normal”. Instead, the responsibility is on society as a whole to include all people, rather than just the lucky few that meet some ridiculous arbitrary standards.

Filed under: fat stigma, health, othering, prejudice, public health, shame, stigmatisation

Fat Shamed by a 7 Yr Old

2013-06-13T21:10:40-07:00

Kids are weird; they're trying so hard to figure out how to be themselves, and behave properly, and learn all this stuff about what it means to be a person and an adult and all the rest that I'm surprised their heads don't explode. I have two of them, ages 10 months and nearly 7 years old, and they equally delight and amaze, and horrify me, almost on a daily basis.

Case in point; last Sunday we were getting ready to go out to Goldstream Provincial Park for the afternoon and Gabe decided to see if he could get a rise out of me by commenting on what I was wearing. I was brushing my teeth or doing my hair, something in the bathroom infront of the mirror at any rate, and he comes in, stands beside me and the following happened:

Gabe: Mom, you look really fat in those pants.

Me: ... Well, I am fat, so I'm going to look that way no matter what I wear.

Gabe: You shouldn't wear those pants. They make you look really really fat.

Me: ... I'm ok with that. I'm not going to get changed, I like these pants.

Gabe: No, mom! You look ugly. Don't wear those!

He seemed to be more upset that I wasn't taking the bait and getting mad about what he was saying than actually disliking what I was wearing. I'm not about to be fat-shamed and fashion police-d by my own kid, so at this point he got a 10 minute time out for extreme rudeness. It's my hope that by keeping my cool and not reacting in a big way that he'll realize that being called fat isn't an insult and not do it to other people trying to hurt them.

Pretty in Pink

2013-06-14T07:24:03-07:00

Tuesday afternoons, I sell my candy at a local-ish farmer’s market. Only, this past Tuesday it was so hot (over 100 degrees Fahrenheit!) I made the executive decision not to do that. At temperatures that high, there’s a serious danger of my caramels melting.

Since I had an unexpected afternoon free, I decided to make some cupcakes.

Just a cupcake, nothing special here.

It turned out pretty and tasty, so I thought I’d share what I did.

I found the recipe on Sally’s Baking Addiction, under Very Vanilla Cupcakes. I used sour cream where it called for Greek yogurt (as I didn’t have any yogurt in the house, time to make more!), and used one egg instead of two egg whites. Then I baked the cupcakes until done.

After the cupcakes were cool, I made the strawberry buttercream frosting.

Strawberry Buttercream Frosting

1 cup butter, room temperature (and yes, it MUST be real butter)
3 cups powdered sugar
2 tablespoon cream
4 tablespoons strawberry puree

Cream the butter for six to eight minutes. It’s very important to do this, as it’s what gives the very creamy, melt-in-your-mouth texture. Once the eight minutes are up, slowly add the powdered sugar, and beat until it’s stiff. Add the cream and strawberry puree and beat for about three or four minutes longer.

Put into a piping bag with a large star tip, and pipe onto the cooled cupcakes.

Take one large strawberry for each frosted cupcake, and slice it thin, but not all the way through. Fan the slices out, and stick them on top of the frosting, pushing them down a little.

Top it all off with some chocolate syrup. I made my own syrup, because I am just a bit crazy like that, but regular chocolate syrup is good too.

It tasted as good as it looks.

Let me know what you think of it if you try it out!

Filed under: Foodie Friday