Introduction

One of the most effective means currently available to individuals seeking to lose weight is bariatric surgery. Bariatric surgery, also known as weight-loss surgery, refers to a number of different procedures, all of which aim to induce severe weight loss through the surgical reduction of the stomach and/or intestines (e.g., [1–4]). Bariatric patients often have a history of complex anxieties and negative social experiences stemming from weight stigma [5–8]). The weight loss that accompanies the surgery, therefore, has been generally related to positive changes in body image and social interactions [9, 10].

In Brazil, bariatric procedures have been available at no cost to patients since 1999 through the Unified Public Health System or the Sistema Único de Saúde [11]. In this respect, Brazil parallels certain European countries that have also made bariatric surgeries widely available to citizens within an integrated healthcare system. Brazil is, however, economically, socially, and culturally quite distinct from these other nations. The sociocultural implications of the surgery, including experiences around weight stigma, have been understudied in a Brazilian context. For example, despite the highly-publicized increase in the number of bariatric surgeries performed within the Brazilian public health network, many experts still consider this number insufficient, as only about 8% of all applications for surgery are approved and financed [12]. Also, there are regional inequalities, with the wealthier South and Southeast regions reporting the most bariatric surgeries, and the North and Midwest regions reporting the least [13].

Stigma can be defined as negative judgments and behaviors aimed at a devalued attribute or condition that disqualifies a person or family or community with this attribute or condition from full social acceptance in a particular cultural context. Stigma results from a cascade of social interactions, in which the individual (or family or community) exhibiting the stigmatized trait is distanced from others, all of whom supposedly adhere to a normative standard. This in turn legitimizes various social and economic discriminations and exclusions [14]. Weight stigma is the process by which people with higher body weights are socially classified as less valuable or desirable because of their weight [15]. Following Brewis [16], we define weight stigma as moral discrediting that people experience from others or apply to themselves because of the negative social meanings attached to the size of bodies. Stigma related to very large bodies tends to be especially pernicious. Weight stigma has been identified as an important barrier to obtaining consistent healthcare services [17] and has significant emotional and social impacts for people who are identified as obese [15, 17–21].

People with higher body weights often internalize weight stigma and end up agreeing with dominant social messages stating that the adverse judgments of them based on their weight have merit [15, 21, 22]. It is also common that people who have been labeled as “obese,” “overweight,” and/or “fat” feel individually responsible for making specific choices around diet and exercise to achieve a more socially acceptable body, i.e., a thinner body. This idea that individuals should make “good choices” is centered in powerful sociocultural notions around the responsible management of the physical body and in the social science literature has been interpreted as a form of moral biocitizenship [23, 24].

Some previous research, including research within Brazilian populations, has indicated that people with a higher body weight consider bariatric surgery a means to achieve a thinner body, and one that is less subject to the negative judgments of others [25, 26]. Nonetheless, studies also suggest that stigma persists in different forms after bariatric surgery. This persistence may involve negative judgments regarding the decision to do such a procedure and/or of the post-surgical body, and may therefore influence the candidate’s post-surgical dietary adherence and overall well-being [4, 27–29]. For example, one study [6] showed that participants who underwent bariatric surgery often heard from their familial and social circles that bariatric surgery was an “easier” method of weight loss in comparison to traditional methods centered on diet and exercise. These traditional methods are often framed as involving moral biocitizenship and “hard work” done upon and with one’s physical body. Doing something the “easy way” was therefore equated with “cheating” at weight loss and thus was a mechanism of stigma creation.

Other research has shown profound shifts in people’s lived experiences in the years after bariatric surgery, mirroring their bodily transformations [30–33]. Negative judgments of post-bariatric bodies are commonly reported in the literature, often centering on the persistence of side effects from the surgeries [34–38] and/or difficulties with managing the rigid personal habits the surgeries necessitate [32–38]. Other negative judgments stem from the shapes and sizes of the bodies produced by the surgery and its accompanying rapid weight loss. Weight loss induced by surgical intervention is so rapid, for example, that it often produces a great deal of excess skin. Furthermore, people tend to lose weight in their heads, arms, and legs before they lose it in their torsos [4]. This pattern of weight loss and loose skin does not always conform to societal body shape ideals, especially for women.

Little is currently known about how women at different life stages (i.e., adulthood vs. elderhood) deal with the profound body transformations caused by the surgery and attendant weight stigma or whether life stage affects the ways in which women assume personal responsibility for maintaining their modified bodies after bariatric surgery. From the more generalized body image literature, we know that body dissatisfaction tends to be fairly stable or to decrease across the life span [39]. However, most studies have not focused on those who lose weight but rather on those who gain weight as they age [40]. Some studies, mostly based in the US and Europe, have shown that older women experience increased body concern as they grapple with feelings of being “trapped” in aging bodies [41]. Higher body weights (past or present) may therefore interact with age and experiences of weight stigma and negatively impact wellbeing in women’s later years. As yet, there is little study on this specific point.

Finally, there is a dearth of research on bariatric surgery and other extreme weight loss experiences in the Global South. Brazil is an interesting location to conduct research in this area of study for a number of reasons, including the fact that sociocultural messages about the “beautiful body”–characterized in women by a thin waist but big breasts and bottoms–are extremely powerful (e.g., [42]). Moreover, the universal healthcare system is offset by extreme socioeconomic inequities, and attitudes about women (both in terms of their relationships with their families and as citizens of the Brazilian state) are undergoing rapid transformation [43].

Therefore, in this study, we aimed to qualitatively understand how weight stigma has affected Brazilian women who have undergone bariatric surgery. Beyond its unique focus on Brazil, our study’s novel approach centers on an age-based description of older and younger women after bariatric surgery, with a particular focus on older women since their experiences are not well documented in the literature. We also were interested in understanding how the participants perceived and internalized (or not) weight and other types of stigmas before and after surgery and how they dealt with the bodily and eating-based transformations brought on by the surgery. Our study can suggest whether a targeted approach might be more effective, for example, an approach that would emphasize the importance of developing coping strategies with respect to experiences of stigma and discrimination after surgery.

Methods

Results

All thirty women who participated in this study underwent bariatric surgeries between 2016 and 2019, before the onset of the COVID-19 pandemic. We provide an overview of the general characteristics of our participant sample in the table below (Table 1). This information was obtained directly from the participants during the individual interviews (see S1 File).

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Table 1. General characteristics of women participating in the study.

São Paulo, Brazil, 2020.

https://doi.org/10.1371/journal.pone.0287822.t001

Overall, we found that after bariatric surgery and its accompanying weight loss, our participants reported that they experienced higher social acceptance in their daily interactions and less discrimination and overt oppression, but they also said that they still faced internalized and reproduced weight stigma. In addition, they assumed specific body-centered attitudes and dealt with conflicting messages regarding their bodies after the surgery. Their interviews yielded four themes regarding these experiences, detailed below, with particular attention paid to the experiences of the older women. All the excerpts that are italicized and have quotation marks around them are English translations and/or original Brazilian Portuguese quotations from the interviews. We could not include all of the original Portuguese quotes due to length limitations, but we consider the inclusion of those highlighting key sociocultural concepts and phrases of vital importance in understanding the participants’ points of view.

Discussion

In this study, we aimed to understand the ways in which weight stigma affected a group of Brazilian women who underwent bariatric surgery. We were also interested in understanding how women at different life stages (i.e., adulthood vs. elderhood) dealt with the profound transformations caused by the surgery and attendant weight stigma.

Participants agreed that surgery itself was stigmatized, particularly because it was considered an “easy way out” to lose weight. This same theme of stigma related to surgery as “cheating” has also been observed in ethnographic studies of bariatric patients in the US and Canada [6, 48–50]. Similar perceptions have been documented within Australian [27, 51, 52], Norwegian [53], and English and Scottish [33, 54] populations. In these neoliberal contexts, being thin is seen as a personal responsibility [55], and our results suggests that this sample from Brazil seems to conform to this same theoretical framework. This was observed, for example, when different people suggested that participants did not try “hard enough”, with their own personal resources, to meet slender norms, and instead had the bariatric surgery.

Although there is quantitative research on the health-related consequences of bariatric surgery in older patients [55, 56], there is a dearth of qualitative data on the experiences of this population. Our study provides some insight into the experiences of older women who undergo bariatric surgery. For example, our older participants received more mixed messages about their decision to undergo bariatric surgery–part of why they felt more stigma. When women started losing substantive weight, they reported that family members and friends wanted them to eat more and to return to their previous, larger sizes–but older women were more often told that weight loss made them look elderly. Studies of bariatric populations in other national contexts have documented similar communications from friends and family with patients (e.g., [4, 6]). What was novel about our findings is that the women interviewed, and especially the older women with whom we spoke, consistently expressed the strong belief that they just needed to accept negative feedback from their families and communities. This stated acceptance is different from the Brazilian study of Liebl et al. [57] with younger participants, where participants stressed that they did not allow negative, unsupportive people to influence their health decisions. This finding also differs from the findings of a study in the U.S. across age cohorts [4], whose participants similarly stressed that they did not listen to people who said negative things to them post-surgery. In our study, some of this stated acceptance possibly reflects dominant social mores and attitudes around women, and in particular older women [58]. Our study therefore underscores the complex connections between weight and age stigma in the Brazilian context [59].

The bodies of our participants after bariatric surgery were a specific source of stigmatizing messages from others. Our participants expressed an underlying feeling that they were always under evaluation to see if they would maintain the expected body weight (and, for the older participants, an acceptably aging appearance). Our results show that these Brazilian women faced serious obstacles to moving beyond the stigma of their weight–even after losing weight. Studies have shown that, in Brazil, the body that is desired is the one that is worked on, cared for, unmarked (e.g., without wrinkles, stretch marks, cellulite, blemishes), and one without excess “fat” [60–64]. Brazilian self-care through exercise, weight management, and cosmetic procedures (among other interventions) is seen as essential to modern Brazilian femininity [64]. In this context, a failure to produce the desired body even after a weight loss surgery potentially connects directly to individual moral failures, which may have the potential to lead to negative mental health outcomes.

Stevens [65] points out that the symbolic “fat” body, which was viewed as “out of control” before bariatric surgery, ideally becomes a slimmer and more disciplined body afterwards. This transformation is understood to be ensured by strict adherence to a particular lifestyle and to disciplinary tools (e.g., physiological limitations and dietary restrictions) that distanced people from the formerly higher-weight, stigmatized body. Participants repeatedly reported feeling the necessity to demonstrate to other social actors (like friends and family) their ongoing commitment to weight loss and to eating with “control.” Similarly, one participant shared that the surgery gave them a chance at a “good” body: a disciplined, non-obese, not-“fat” body. We suggest that our participants understood weight gain to be a return to a “bad” body, since a “bad” body is indicative of a bad person, and a moral failure in this context. As we noted at the outset, this idea that individuals should make “good choices” is centered on the requirement of responsible management of the physical body in order to be a functioning, moral biocitizen [23, 24]. Among our older participants, this seemed to be entangled further with experiences of what was interpreted as ageism: a stereotypical and often negative view of older people as less competent [66]. This view exacerbated attempts by others to monitor the older women.

Our participants, especially older women, commonly stated that external warnings, admonitions, restrictions, and advice needed to be tolerated and were even warranted. This may suggest an internalization of certain kinds of stigma by these women–that they believed the stereotypes stating that because they had a higher body weight and/or because they had bariatric surgery and/or because they were older, they were somehow less disciplined and less competent and required supervision by others. Alternatively, it could reflect women’s belief in certain age-related and feminized norms, i.e., one must accept one’s family’s advice and dictates. Illustratively, studies have shown that Brazilian culture encourages acceptance of a situation, as well as lack of inquiry into its causes [67].

In a U.S. study, the authors stressed the importance of the bariatric program’s pre-operative educational classes and post-operative support group in patient long-term success. These classes and groups provided participants with a framework and preparation for understanding the many reactions that their social and work circles might have after bariatric surgery [4]. Most importantly, perhaps, the classes also encouraged challenging situations if they did not enhance wellbeing post-surgery. Although our participants also had pre- and post-operative support groups, this support may have been insufficient to combat stressful social messaging, especially if the support focused exclusively on clinical questions and issues.

Our participants also expressed stigmatizing views regarding other people who gained weight after surgery. For them, those who gained weight must not have been good biocitizens, since biocitizens should be able to demonstrate vigilant and controlled eating. In making these judgments, participants reproduced a moral biocitizenship [23, 24] themselves, as they discussed peers’ mistakes and habits as not-quite-compliant-enough post-bariatric citizens. They internalized that the right way to live after bariatric surgery is to have “willpower,” “control,” and a “good mentality.” Their narratives showed that they tried their best to put this thinking into daily practice, even as their virtuous efforts were called into question when they themselves gained weight or found themselves unable to sustain weight loss. Keeping this articulated perspective (willpower-control-good mentality) at the forefront made participants feel that they were genuinely compliant with what was necessary to succeed after bariatric surgery. This attitude, as reported to us, differentiated them from the “others” (i.e., the “unsuccessful” bariatric colleagues) and resulted in our participants producing themselves as normative subject-citizen-bodies. Participants in the U.S. showed this judgement as well [4]. These attitudes suggest that people who have undergone bariatric surgery, even across different sociocultural or clinical contexts, continue to perpetuate weight stigma.

Finally, it is important to reflect on the impact that the COVID-19 pandemic had on our study and participants. We conducted our research in 2020, at a time when there was collective anxiety about weight gain during lockdown and extensive media messages about higher body weights being a risk factor for COVID-19 complications. It is likely that this historic moment reinforced already existing weight stigma [68–70].

Reflecting on the authors’ motivations and positionality with regard to this research, we recognize our privileges as white, middle/upper-class researchers. Also, as of this writing, none of us have a higher body weight. Despite this limitation, we all have been extensively studying weight stigma and the critical weight literature for years. Also, in our previous research, we have been actively listening to women with a higher body weight for years–in some cases, for decades.

Study limitations include the sometimes lengthy periods of elapsed time between the surgeries of participants and the interviews we conducted with them, which may have inconsistently influenced responses. This differential time lapse between the surgeries and participation in the study is, however, similar to other studies with post-bariatric population, which included participants with a mean of 7.7- and 13.7-years post-surgery [71]. Furthermore, the varied lengths of time since surgery meant we captured a diverse set of experiences post-surgery, as the women participants developed increasingly divergent trajectories after the first post-operative months.

Conclusion

Our Brazilian participants faced stigma related to having bariatric surgery, as well as to their body weight. Many of the themes (e.g., surgery as “cheating” and the need to constantly perform self-monitoring) are similar to those identified in studies in the U.S. and Europe. An age-based thematic description of the views and experiences of Brazilian women who underwent bariatric surgery illuminates, in particular, that older women’s experiences were more negative than those documented in the weight stigma literature to date. Our results show that people demanded linear weight loss post-surgery but also connected a certain appearance of thinness to “ugliness”, “sickness”, and, among the older women, “aging”. Thus, a complex web of factors determined which bodies were considered acceptable or not across different lifecycles. The older women also frequently heard from the people around them that the side effects of the surgery were worse than having a higher body weight. All these aspects point to a complicated, possibly globalized or globalizing [72] connection between weight and age stigmas. We suggest future studies in the Global South focus on this understudied phenomenon. Also, future research should explore whether a targeted approach might be more effective, for example, an approach that would emphasize the importance of developing coping strategies with respect to experiences of stigma and discrimination after surgery.

Supporting information