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  • Disease First, Coverage Second: Germany’s Reimbursement Debate Comes With a Price Tag

    Disease First, Coverage Second: Germany’s Reimbursement Debate Comes With a Price Tag

    The new chair of Germany’s most powerful health body has said something nobody in that chair has said before. She also named, quite precisely, what it would cost.

    Sonja Optendrenk has led the Gemeinsamer Bundesausschuss (G-BA) since early July 2026. The G-BA is the joint self-governing body that decides which treatments the statutory health insurers reimburse for 74 million insured people in Germany. In early August she told the news magazine Der Spiegel that it would be worth considering recognising weight-loss drugs as a reimbursable benefit under certain conditions. In her words, as reproduced by the dts news agency and by Tagesspiegel: Germany is having “a backward discussion about obesity”. Other countries, she said, notably the United Kingdom, have “consistently accepted that this is a real illness that cannot be reversed by sport and better nutrition alone”.

    This is a proposal, not a decision. But it comes from the office that would have to write the details, and it is more specific than such proposals usually are.

    What the statute actually says

    The reason Wegovy and Mounjaro are paid for out of pocket in Germany sits in section 34, paragraph 1 of the Fifth Social Code. It excludes medicines whose use primarily serves “an increase in quality of life”. Then comes a list worth reading in full. Excluded in particular are medicines predominantly used:

    • to treat erectile dysfunction
    • to stimulate or increase sexual potency
    • for smoking cessation
    • for slimming or appetite suppression
    • to regulate body weight
    • to improve hair growth

    That is the company fat bodies keep in German social law: filed between potency drugs and hair growth. Not as an accident of drafting, but as the law in force.

    Optendrenk points at exactly that. The fact that drugs explicitly licensed to treat obesity fall under this paragraph is, for the people affected, “a sign that this recognition is missing”.

    It is the most honest description of the problem to come from that direction so far. The issue is not only money. It is which list a body gets sorted into.

    The precedent is sitting in the same section

    What separates this from a statement of intent is that the template already exists one paragraph down.

    For smoking cessation, the legislature has already broken its own rule. Section 34, paragraph 2 gives insured people with a diagnosed severe tobacco dependence a claim to a one-time supply of cessation medication, but only within evidence-based programmes. A repeat supply is possible no earlier than three years after the first course ends. And the specifics, which drugs under which conditions, are set by the G-BA in its own guidelines.

    So smoking cessation remains on the exclusion list in paragraph 1 and still has a narrow, conditional claim in paragraph 2. The legislature cuts the exception, the committee fills it in.

    That is precisely the mechanism Optendrenk floated: the legislature could instruct the G-BA to determine which patient groups should receive the drugs, for how long, and with what accompanying measures. Anyone wanting to know what that looks like in practice does not have to speculate. The tobacco rule is the blueprint: a certified severity, a programme around it, a waiting period.

    The price is written into the same sentence

    This is where it gets complicated for fat people rather than simply good.

    In Optendrenk’s own argument, the route to coverage runs through recognition as a disease. The UK, she says, accepted that this is a real illness. Access follows once the body counts as requiring treatment.

    That is the same logic German guideline medicine runs on. The national obesity guideline added a dedicated chapter on stigmatisation in 2024, and that chapter closes by arguing that recognising obesity as a disease implies making billable treatment available nationwide. Destigmatisation as the argument for more treatment. We set out the fault line in our guide to what Health at Every Size actually means: one framework says care should not have to be earned, the other says care arrives once the body carries a diagnosis.

    Both beat the status quo, in which fat people are neither recognised nor treated. But they are two different futures. In one you get care because you are a person. In the other you get it because you are a case.

    Her own caveat is the most interesting part

    Optendrenk limited her own proposal, and more sharply than the headlines suggest: “As long as the weight comes straight back after stopping, an injection alone is not a model of care.” Long-term studies, she noted, are missing.

    That sentence can be read two ways, and both readings will be used in the coming months.

    Read weight-neutrally, it says: a drug whose effect ends when you stop taking it is no substitute for care that takes fat people seriously. That matches what the research already shows, and it argues against the idea that a prescription settles the matter.

    Read from the industry side, the same sentence says: if the weight comes back after stopping, then nobody should stop. A time-limited treatment becomes permanent medication, and a line item becomes a subscription. Anyone who has followed the American coverage fights knows this argument. We traced the access question across countries in France pays, Germany does not and the class dimension in the GLP-1 access gap.

    Which reading wins will not be decided by her sentence. It will be decided by whoever gets to define the accompanying measures she mentioned.

    What it means in practice

    In the short term, nothing. There is no decision, no instruction from the legislature and no timetable. Anyone who wants a prescription today still pays for it themselves.

    Over the medium term, three things are worth watching, because they decide whether a change creates access or builds a new hurdle.

    The eligibility criteria. Following the tobacco model, some certified severity will be required. For weight that almost certainly means BMI thresholds. Anyone just below falls out, and the line is always arbitrary.

    The accompanying measures. Mandatory programmes can mean good care, or they can mean a compliance test in which reimbursement is tied to demonstrated good behaviour. The difference lives in the detail, and the detail will not be in the statute. It will be in a guideline.

    The side effect on everything else. Coverage coupled to disease recognition reinforces the picture of the fat body as a case for treatment. In the very same practice where it opens access to one drug, it can narrow access to everything else. What that looks like in the room is in our guide to what to do when a doctor blames everything on your weight.

    What we are not doing here

    We are not recommending weight-loss drugs and we are not warning anyone off them. That is a medical decision between you and a practice that takes you seriously.

    The point is a different one. A country that files fat bodies next to hair-growth products in its statute book is, for the first time, hearing from the top of its own health self-government that the sentence might be wrong. That is good news. It just arrives with an invoice, and the invoice reads: diagnosis.

    The cost argument is already being staged, incidentally. Tagesspiegel puts the direct medical costs of obesity and its sequelae in Germany at roughly 29 billion euros a year, citing current calculations without naming them. We report the figure as what it is: a number circulating in the debate whose source we have not checked against the original. Why that is a recurring problem with numbers about fat people is the longer story in who pays for weight stigma research.

    Fatosphere holds one red line: we do not promote diet or weight-loss products, and we do not publish before-and-after logic. This piece reports a health policy debate without recommending any treatment.

    Sources

    • Sonja Optendrenk interviewed by Der Spiegel, reproduced by the dts news agency (Presse Augsburg, 2 August 2026) and by Tagesspiegel (2 August 2026). The interview itself is paywalled; the quoted sentences match across both reproductions.
    • Section 34 of the German Social Code Book V, paragraph 1 (exclusion of medicines primarily serving an increase in quality of life) and paragraph 2 (claim in cases of severe tobacco dependence), read on 5 August 2026 at gesetze-im-internet.de.
    • Deutsche Adipositas-Gesellschaft (lead), S3 guideline Prävention und Therapie der Adipositas, AWMF register number 050-001, version 5.0, 7 October 2024, chapter 2 on stigmatisation.

    Image credit: cover graphic by Fatosphere, generated programmatically. Not a photograph and not a depiction of real people.

  • Fat Men Blame Themselves. Fat Women Blame Them Less.

    Fat Men Blame Themselves. Fat Women Blame Them Less.

    Among Brazilian men with what the study calls Class II obesity, 42.8 percent agree that fat people are personally responsible for their weight. Among women in exactly the same weight category, 15.0 percent agree.

    Same country, same survey, same question, same bodies. Nearly three times the self-blame on the male side.

    That gap has been sitting in a peer-reviewed journal since March 2026, and almost nobody has written about it. Partly because the study came out of Brazil rather than the United States. Partly because fat men are the group that fat activism, fashion media and academic research have all managed to talk about least.

    What the study actually is

    Viola and colleagues published the analysis in Obesity Science & Practice on 9 March 2026. It is a subanalysis of a larger national survey of Brazilian adults conducted by the polling institute IPEC, from which the researchers pulled the 653 respondents whose self-reported height and weight put them at a BMI of 30 or above.

    Of those 653: 368 women, 284 men, one nonbinary participant. Just over two thirds came from socioeconomic class C, the lower-middle band in the Brazilian ABC classification. Roughly 63 percent fell into Class I, 24 percent into Class II, 13 percent into Class III.

    It is an online panel survey with self-reported weight and height, not a clinical study. That matters for how much weight the numbers can carry, and we come back to it below.

    The self-blame gap

    Across the whole sample, 27.5 percent agreed that fat people are personally responsible for their weight. Split by gender, the picture changes shape:

    • Personally responsible: men 35.5 percent, women 21.1 percent (p < 0.001)
    • Lack of willpower: men 30.9 percent, women 20.4 percent (p = 0.002)
    • Lack of desire or low motivation: men 20.0 percent, women 14.1 percent (p = 0.044)

    Three different phrasings of the same moral idea, and men endorse all three more often. In the Class II group the gap widens to 42.8 against 15.0 percent.

    These are fat people describing fat people. This is not the thin majority’s opinion about them. It is the sound of a stigma that has been fully swallowed.

    Why the male number is the one to watch

    The paper does not test explanations for the gender gap, and neither will we. But two other findings from the same sample point in a direction worth naming.

    More than half of the participants had never received a formal obesity diagnosis from a healthcare provider, and men were diagnosed less often than women. Only 40.2 percent reported at least one medical visit a year, and men were more likely than women to report going to a doctor only once in several years.

    So the group that most strongly believes the problem is personal willpower is also the group that shows up least often in a consulting room. Whether the belief drives the avoidance or the avoidance protects the belief, the study cannot say. That the two travel together in the same sample is documented.

    There is a version of masculinity in which asking for help is the failure, not the condition. Fat men appear to be paying for it twice: once in the stigma everyone else applies to them, and once in the version they apply to themselves.

    The 11.6 percent that looks like good news

    The same study asked where fat people face discrimination. The answers, in order: leisure settings 48.2 percent, workplaces 33.4 percent, public transport 33.1 percent, and healthcare at 11.6 percent.

    Read quickly, that looks like a finding: Brazilian medicine has a smaller stigma problem than Brazilian nightlife. Read the question, and it stops looking like that.

    Participants were asked to select up to three everyday situations or places where they believed fat people experience the most discrimination. Two design decisions are doing the work there. The question asks about a general belief, not about the respondent’s own experience. And it caps the answer at three picks, which turns the whole thing into a ranking rather than a measurement.

    A doctor’s appointment happens a few times a year. A bus happens daily. If you can only name three places, the everyday ones win, and the rare, concentrated, high-stakes encounter drops off the list. The 11.6 percent does not tell you how many people were humiliated at the doctor’s office. It tells you how many people put the doctor’s office in their personal top three.

    Two surveys, two numbers, one difference in wording

    Set that against the Swiss Adipositas-Barometer 2026, which we took apart last week. There, 64 percent of self-described affected respondents said they had been discriminated against by health professionals.

    11.6 percent and 64 percent, apparently about the same thing. The gap between them is not a gap between Brazil and Switzerland. It is a gap between two questions.

    The Swiss question asked affected people about their own experience, with no cap and no competition between answer options. The Brazilian question asked all fat respondents to rank the places where they think fat people in general have it worst, three picks maximum. Those instruments cannot produce comparable numbers, and anybody quoting one against the other is comparing a thermometer to a survey of who feels cold.

    This is the part that keeps mattering beyond either study. When a stigma statistic circulates without its question attached, you cannot tell whether you are looking at reality or at the shape of a form.

    Who paid for this one

    Fatosphere asks that about every study now, our own sources included.

    The subanalysis and the parent survey were both funded by Merck KGaA, with support from ABESO, the Brazilian Association for the Study of Obesity and Metabolic Syndrome. The parent survey was carried out by IPEC, a commercial polling institute.

    The declared conflicts of interest run deep into the industry. The lead author reports honoraria from Novo Nordisk and AstraZeneca and travel support from Novo Nordisk, Eli Lilly, PTC Therapeutics and Chiesi. A co-author reports speaker and consultancy fees from Chiesi, PTC, Lilly, Merck, Boehringer Ingelheim-Lilly and Novo Nordisk. Another reports payments from Eli Lilly, Novo Nordisk, Merck, AstraZeneca and Abbott Nutrition, plus advisory board roles at three of them.

    The benchmark study the authors lean on for comparison is ACTION-IO, which is registered to Novo Nordisk.

    None of that makes the gender gap fake. It does mean that the two largest recent data sets on weight stigma we have written about, one Swiss and one Brazilian, were both paid for by pharmaceutical manufacturers. We looked for a comparably sized independently funded alternative and did not find one. If you know of one, tell us.

    What these numbers can and cannot carry

    Three limits, stated plainly, because the study states them too.

    Weight and height are self-reported, so the group labelled “obesity” is a group of people who described themselves into it. Recruitment ran through an online panel, which skews towards people who are online and willing to answer surveys for a living. And the fieldwork date is not given in either paper; the parent article was submitted in September 2024, so the data are at least that old.

    One more, ours rather than theirs: the subanalysis describes the parent sample as 2,650 people in its methods section, while its own abstract and the parent publication both say 2,560. A hundred-person discrepancy in a published methods section is small, but it is the kind of thing that survives into every citation downstream.

    The gap in our own magazine

    We have published twenty articles. Not one of them has been about fat men.

    That is not an oversight peculiar to us. Fat liberation grew out of feminist organising, plus-size fashion coverage is written for women, and the research literature follows the same grooves. Meanwhile the group least represented in all of it is the one turning the blame inward hardest, going to the doctor least, and getting diagnosed least often.

    We do not have a fix to offer in one article. We have a starting point: if you are a fat man who has spent years assuming that the problem is your discipline, the Brazilian data suggest you have plenty of company, and that the belief is a symptom of the stigma rather than a diagnosis of you.

    Three things we have already written are the practical follow-on: what to do when a doctor blames everything on your weight, how to find a weight-neutral doctor, and how to find a weight-inclusive therapist.

    Sources, all read at the primary source on 3 August 2026: Viola L. F. et al., “Obesity-Related Beliefs, Concerns, and Stigmatizing Perceptions Among Adults Living With Obesity”, Obesity Science & Practice 12(2):e70133, published 9 March 2026, DOI 10.1002/osp4.70133, PMCID PMC12971610. Parent survey: Viola L. F. et al., “Exploring the Perceptions of Obesity, Health Habits, Stigma, and Eating Behaviors in Brazil”, Diabetology & Metabolic Syndrome 17:119, published 7 April 2025, DOI 10.1186/s13098-025-01660-5. Swiss comparison figures: gfs.bern, “Adipositas Barometer 2026”, commissioned by Novo Nordisk.

    Fatosphere does not publish diet or weight loss content. This article reports on what surveys about fat people measure and who pays for them. It is not a recommendation for or against any treatment. The terms “obesity” and “Class II” are used here only where they describe the studies’ own categories.

  • Who Pays for the Weight Stigma Study?

    Who Pays for the Weight Stigma Study?

    A new Swiss survey delivers exactly the numbers fat activists have been asking for. Almost two thirds of affected respondents say health professionals have discriminated against them. Nine out of ten people say fat people face contemptuous looks in everyday life. Half the population still believes it comes down to lifestyle and discipline.

    The survey was commissioned by Novo Nordisk, the company that makes Wegovy.

    That is not a scandal, and it is not a reason to throw the numbers away. It is a reason to read them properly. This piece is about how to do that.

    What the Adipositas-Barometer 2026 actually found

    gfs.bern, a Swiss polling institute, surveyed 1,539 Swiss residents aged 16 and over between April and May 2026, plus 116 physicians (general practitioners and specialists in endocrinology, surgery, gastroenterology, and obesity centres). The results are published as an open “cockpit” on gfsbern.ch.

    The stigma findings are blunt:

    • 82 percent of the general population say fat people in Switzerland are strongly or fairly strongly stigmatised. Among physicians, that figure is 97 percent.
    • Only cardiovascular disease (26 percent) and type 2 diabetes (28 percent) score far lower. Mental illness (81 percent) and addiction (79 percent) sit at the same level as fatness.
    • 92 percent agree that fat people frequently face contemptuous looks. 82 percent say they face prejudice from health professionals and at work.
    • Among respondents who described themselves as affected, 64 percent report having been discriminated against by health professionals. 72 percent say shame keeps people from seeking medical help.

    And then the part that makes the study genuinely interesting rather than merely useful:

    • 79 percent of the population accept fatness as a disease requiring treatment.
    • 76 percent say affected people carry a special personal responsibility.
    • 49 percent agree that being fat comes down mainly to lifestyle and lack of discipline.

    The disease framing has won, and the blame has not gone anywhere. Both statements are true at once, in the same population, at the same time. That is the finding worth carrying forward.

    Who commissioned it, and why that matters

    The client is named openly at the top of the cockpit page and again in the methods box: Novo Nordisk. No hiding, no shell foundation, no “unrestricted educational grant” phrasing. Credit where it is due, the disclosure is clean.

    But disclosure is not neutrality. Novo Nordisk sells semaglutide. A study establishing that fatness is stigmatised, medically undertreated, and recognised as a disease is a study whose conclusions run in a commercially useful direction. That does not make the answers wrong. It shapes which questions were asked in the first place.

    The brand questions sitting inside the stigma survey

    Read the cockpit closely and you find something a purely academic stigma study would have no reason to include.

    One section reports how respondents perceive Novo Nordisk specifically: among those who had noticed content about the company, 17 percent rated it positively, 13 percent neutrally, 14 percent negatively, and 42 percent said they had heard nothing specific about Novo Nordisk at all.

    Another section ranks pharmaceutical companies by perceived engagement on the issue. Novo Nordisk leads at 43 percent, ahead of Roche (37 percent), AstraZeneca (28 percent) and Eli Lilly (21 percent).

    That is brand tracking. It is a standard, legitimate market research instrument, and it is embedded in the same questionnaire that produced the stigma numbers now circulating in the press. Whoever cites the 64 percent is citing an instrument that also asked how well the sponsor is doing against its competitors.

    The policy question that pays the sponsor

    Physicians in the survey were asked to rate how effective various measures would be. Among the options offered: “relaxed reimbursement criteria for medications.” 76 percent rated that effective.

    The number is real. The framing is worth noticing. A survey does not discover that respondents want looser reimbursement rules. It offers the option and counts the ticks. The measure that would most directly expand the sponsor’s market was one of the items on the list, sitting between “better representation of services in the tariff system” and a “national action plan.”

    Again: this is how commissioned research works everywhere, in every industry. It only becomes a problem when the resulting number is later quoted as if physicians had raised the demand spontaneously.

    What the sample can carry, and what it cannot

    The methods box reports a sampling error of plus or minus 2.5 percentage points at a 50/50 split. That figure applies to the full population sample of 1,539.

    It does not apply to the subgroup that produced the most quotable findings. Nine percent of respondents described themselves as affected. That is roughly 139 people, and the cockpit does not publish a separate n for this subgroup or a separate margin of error for it. The 64 percent discrimination figure, the 72 percent shame figure, the 43 percent who found treatment costs a heavy burden: all of these rest on that small subgroup.

    They are still worth reporting. They are not worth reporting to the decimal point, and they are not worth treating as equivalent in precision to the headline figures. Anyone quoting them should say which base they come from. Most of the coverage does not.

    This is not a one-off

    The pattern is older and larger than one Swiss survey. The most widely cited international research on perceptions and barriers in obesity care carries the same sponsor.

    ACTION-IO, the eleven-country survey of people with obesity and healthcare professionals published in Diabetes, Obesity and Metabolism in 2019, is registered at ClinicalTrials.gov as NCT03584191. Lead sponsor: Novo Nordisk A/S. Its US predecessor, the ACTION study (NCT03223493), is registered to the same company.

    These studies are the source of the frequently repeated statistics about how few fat people are offered structured care and how rarely doctors raise the topic. They are, as far as we can tell, methodologically competent. They are also, without exception, funded by a company that sells the treatment the studies conclude is underprovided. The same asymmetry shapes who can actually get these drugs, which we looked at in Fat and Poor: The GLP-1 Access Gap Punishes Twice and in Covered in France, “Lifestyle” in Germany.

    We have not found a comparable body of independently funded international research at that scale. If it exists, we would like to hear about it. Either way, the difficulty of finding one is itself a finding about who gets to fund knowledge about fat people.

    Why we use the numbers anyway

    The alternative to citing sponsored research is citing nothing, because for many of these questions nothing else at this scale exists. Refusing the data does not produce better data. It produces silence, and silence has never been on our side.

    So we use them, with three rules:

    1. Name the funder in the same sentence as the number. Not in a footnote, not at the end.
    2. Separate the descriptive findings from the policy conclusions. “Two thirds of affected people report discrimination by health professionals” is a description. “Therefore reimbursement criteria should be relaxed” is a conclusion the sponsor benefits from, and it does not follow automatically from the description.
    3. Say what base the number rests on.

    What nobody asked

    The most revealing thing about a questionnaire is usually the question that is missing.

    The Adipositas-Barometer asks at length about treatment: which therapies people used, why they stopped, whether reimbursement should be easier, whether interdisciplinary structures are missing. The list of reasons for discontinuing treatment includes “reached target weight” as an endpoint.

    It does not ask whether care could be organised so that fat people receive competent treatment for the thing they actually came in for. It does not ask whether stigma might be reduced by changing how practices work rather than by expanding what they prescribe. It does not ask affected people whether they want their bodies treated at all. What competent care would look like instead is the subject of our guide to finding a weight-inclusive therapist.

    Those questions are answerable. They are just not the questions a pharmaceutical company has a reason to pay for. Until somebody else pays, they will keep not being asked, and the evidence base will keep pointing in one direction because that is the only direction anyone bought a map for.

    Sources, all read at the primary source on 2 August 2026: gfs.bern, “Adipositas Barometer 2026”, cockpit.gfsbern.ch, commissioned by Novo Nordisk, fieldwork April to May 2026, N=1,539 population and N=116 physicians, project code CH26OB00079_06/2026. ClinicalTrials.gov entries NCT03584191 (ACTION-IO) and NCT03223493 (ACTION), lead sponsor Novo Nordisk A/S.

    Fatosphere does not publish diet or weight loss content. This article reports on how research about fat people is funded and framed. It is not a recommendation for or against any treatment.

  • Covered in France, “Lifestyle” in Germany: Europe’s Split on Weight-Loss Drug Coverage

    Covered in France, “Lifestyle” in Germany: Europe’s Split on Weight-Loss Drug Coverage

    Since 15 June 2026, France’s statutory health insurance reimburses Wegovy and Mounjaro at 65 percent. Germany lists the same two products, by name, as lifestyle drugs, in the same legal category as products for hair growth and erectile dysfunction. Same continent, same molecules, opposite answer.

    This article is not an argument that anyone should take these drugs, and it is not a recommendation to lose weight. Fatosphere does not do either. It is about something else: two European states looking at identical evidence and deciding, in opposite directions, whether care for fat people is medicine or a matter of personal taste. And about the fact that both systems, in different ways, make fat people justify themselves first.

    What France decided

    Two ministerial orders published in the French Journal officiel on 28 May 2026 added Wegovy (semaglutide) and Mounjaro (tirzepatide) to the list of reimbursable medicines. Reimbursement started on 15 June 2026 at 65 percent, meaning a patient share of 35 percent, with full coverage possible depending on individual status, long-term illness (ALD) recognition and supplementary insurance.

    The conditions are narrow. The French government’s own citizen information service describes the eligible group as people who would qualify for bariatric surgery: a BMI of 40 or higher without a weight-related comorbidity, or 35 or higher with at least one. The drugs count as second-line treatment, permitted only after a documented failure of nutritional management, which the same page defines as less than 5 percent weight loss after six months. They must be prescribed alongside a hypocaloric diet and increased physical activity.

    Who may prescribe is restricted too. According to the French health insurance service Assurance Maladie, the first prescription that triggers reimbursement is reserved for specialists working in obesity care: specialised obesity centres, university hospitals, certain rehabilitation and nutrition units, or endocrinologists working with such a centre. Renewals can then come from a general practitioner. An accompanying form has to be filled in once by an authorised doctor, given to the patient and handed to the pharmacist at every dispensing. People who were already buying these drugs privately before 15 June need that form as well if they want their prescriptions reimbursed.

    What Germany decided

    Germany did not reject reimbursement after weighing the evidence. It never got that far, because the question was settled in 2004.

    Section 34 of the German Social Code, Book V, excludes from statutory coverage all medicines whose use is primarily about increasing quality of life. The statute then names its own examples. In the original German wording, the excluded categories are drugs used mainly for erectile dysfunction, for arousal and increasing sexual potency, for smoking cessation, for slimming or curbing the appetite, for regulating body weight, or for improving hair growth (our translation). Body weight sits in that list, in that sentence, next to hair.

    On 21 March 2024 the Federal Joint Committee, the G-BA, formally added Wegovy to Annex II of its medicines directive, the annex headed “lifestyle drugs”. Its own press release is unusually candid about how little room it had. During the consultation the committee considered demands for an exception at least for people with a BMI above 30 and weight-related conditions, and concluded that it had no discretion to grant one. The same release notes a consequence that is easy to miss: because the exclusion attaches to the approved indication, Wegovy also cannot be included in Germany’s structured treatment programme for obesity, the DMP Adipositas, which the G-BA had just adopted. The state runs a structured disease management programme for the condition and is legally barred from putting the drug into it.

    Mounjaro followed on 19 September 2024. The committee’s own note on that decision states the reasoning plainly: classification as a lifestyle drug is not defined by the disease value of the underlying indication. It follows instead from the match between the approved use, weight reduction, and the examples written into the statute. The committee cites a 2012 Federal Social Court ruling (B 6 KA 50/11 R) for the proposition that it has no discretion here, and calls its own listing merely declaratory.

    Read that again, because it is the whole point. Germany’s health authority is not saying that fatness is not a medical matter. It is saying that the question does not arise. The label says weight regulation, the statute says weight regulation, and everything else, including whether the person in front of you is ill, is legally irrelevant.

    One molecule, two names, two answers

    Semaglutide is sold in Germany as Wegovy, Ozempic and Rybelsus. Ozempic and Rybelsus are approved for type 2 diabetes and have been reimbursable since they entered the market. Wegovy is the same active substance, approved for weight regulation, and is not reimbursable. Tirzepatide works the same way: excluded under the Mounjaro weight-regulation indication, still a statutory benefit for type 2 diabetes.

    The chemistry does not change at the pharmacy counter. What changes is which sentence on the marketing authorisation the insurer reads. A body that has already developed diabetes gets treatment paid for. The same body one diagnosis earlier does not.

    Both systems make you prove something first

    It would be easy to read this as France good, Germany bad. It is not that simple, and the French rule deserves the same scrutiny.

    To qualify in France you must first have failed. Not failed in a vague sense: the criterion is a documented course of nutritional management that produced less than 5 percent weight loss in six months. Dieting is not merely permitted alongside the drug, it is the entry ticket, and the drug is only unlocked once the diet has demonstrably not worked. The state has written the logic of diet culture into a reimbursement rule and given it a form number. Then it requires the diet to continue anyway, since the prescription is only valid alongside a hypocaloric regime and increased physical activity.

    Germany’s version of prove it is shorter and blunter. There is nothing to prove, because the category has already been decided. If you want the drug you pay for it yourself, and if you cannot, that is treated as a private matter about quality of life.

    Both are moral tests. One asks you to document that you tried hard enough. The other tells you the whole area is your own business. Neither starts from the question a health system is supposed to ask, which is what this particular person actually needs.

    The contradiction Germany has not resolved

    Germany’s own institutions do not agree with each other.

    Bariatric surgery is a statutory benefit. The drug is not. That gap is exactly what the petition behind a November 2025 decision of the Bundestag’s petitions committee was about: the petitioner argued that stomach reduction surgery plus lifelong follow-up costs more than lifelong drug treatment. On 12 November 2025 the committee decided, by a broad majority, that reimbursement in cases of medical necessity was “worth considering”, and recommended forwarding the petition to the Federal Health Ministry “as material”. In its reasoning it pointed straight back at section 34 and the lifestyle category, and said conclusive long-term data on cardiovascular endpoints and drug safety should be awaited.

    Worth considering and as material are the parliamentary vocabulary for nothing happening yet. Nine months later, nothing has. And because the G-BA has already stated that it has no discretion, this cannot be fixed by the committee that made the listing. Changing it means changing the statute, which is a job for the legislature, not the regulator.

    Why we are writing about this at all

    Fatosphere does not tell anyone to take these drugs, and we do not treat weight loss as a goal worth pursuing. Our interest in GLP-1 policy has always been the same one: what it reveals about who is allowed access to medical care, and on what terms.

    Until now we could only tell that story with American material, where private insurers, Medicaid programmes and federal pilots open and close the door month by month. France and Germany let us tell it inside one continent, under two systems that both claim to cover everyone. A person with the same body, the same diagnoses and the same doctor gets a different answer depending on which side of the Rhine they live on. That is not medicine. That is administrative geography.

    And the German category is worth naming for what it is. Placing body weight in a legal list with hair growth and sexual potency was a political choice made in 2004, at a time when almost none of the current evidence existed. It has since become a rule that its own enforcers say they cannot bend. Whatever you think about these drugs, and there are good reasons for scepticism about a market this loud, a health system that decides in advance that the topic is a matter of lifestyle has stopped asking the medical question. It has just made the answer someone else’s problem.

    What we are watching

    • Whether the Federal Health Ministry does anything with the petition it received as material in November 2025.
    • Whether France’s narrow criteria hold, and who ends up excluded by the requirement to have documented a failed diet first.
    • Whether other EU states follow one model or the other, which will show whether the French decision was an outlier or the beginning of a split.

    Related reading

    Our earlier work on the same question, from the American side: Fat and Poor: The GLP-1 Access Gap Punishes Twice. On rights in and outside the doctor’s office: When the World Isn’t Built for You: Weight Discrimination, and What to Do About It and What to Do When a Doctor Blames Everything on Your Weight.

    Sources

    • Service-Public.fr (Direction de l’information légale et administrative), “Deux médicaments contre l’obésité remboursés depuis le 15 juin”, published 1 June 2026, updated 15 June 2026.
    • Assurance Maladie (ameli.fr), “Obésité : de nouveaux médicaments peuvent être pris en charge dans des conditions encadrées”, 16 June 2026.
    • Section 34 of the German Social Code Book V (SGB V), full text at gesetze-im-internet.de.
    • Gemeinsamer Bundesausschuss, press release, “G-BA vollzieht den gesetzlichen Verordnungsausschluss für das Abmagerungsmittel Wegovy nach”, 21 March 2024.
    • Gemeinsamer Bundesausschuss, professional news item, “Tirzepatid und Ritlecitinib als Lifestyle-Arzneimittel gelistet”, 20 September 2024, on the decision of 19 September 2024.
    • Deutscher Bundestag, hib 605/2025, “Übernahme der Kosten für die Abnehmspritze durch die GKV”, 12 November 2025, on petition ID 165851.
  • How to Find a Weight-Inclusive Therapist

    How to Find a Weight-Inclusive Therapist

    Therapy is supposed to be the one room where you are not the problem. For people in larger bodies, that is not reliably true. The research on this is no longer thin, and it is not flattering to the profession.

    This guide is about the practical part: what “weight-inclusive” actually means, which directories exist and what each one really does, what to ask before you book, and what to do when the directories come up empty where you live.

    Why this search is worth the effort

    A 2025 scoping review in Frontiers in Psychiatry pulled together 43 studies on weight bias in mental health settings (Philip, Standen, Schueler, Fields and Phelan, Weight bias in mental health settings: a scoping review, Front Psychiatry 2025;16:1596625, screened from 11,035 records). Three findings from it matter for anyone choosing a therapist.

    Body size changes the clinical picture practitioners see. Across experimental studies, clinicians were given identical case descriptions that differed only in the client’s body size. Higher-weight clients were rated as having lower global functioning, more pathology, more negative attributes and more severe diagnoses than lower-weight clients with the same presenting problem. In one study, the higher-weight client was more likely to be recommended weight loss strategies than clients in the other conditions, for a case that was otherwise identical.

    The bias runs in both directions, and the second direction is the dangerous one. When the vignette described restrictive eating disorder symptoms, higher-weight clients were rated as less severe and recommended less intensive treatment. One 2024 study in the review found that low-weight clients were more likely to be labelled with an eating disorder, more likely to be described as restricting, and more likely to be referred to specialist treatment and medical follow-up than clients at average or higher weight presenting the same symptoms. Restriction in a fat body gets read as discipline.

    Training programmes mostly do not cover it. In one study cited in the review, 76 per cent of participants said bodies were discussed “rarely” or not at all in their programme, and around half of the students said they felt incompetent working with body image in session. Roughly six in ten students said their programme did not encourage them to reflect on body size as a cultural identity or to examine their own assumptions about larger people.

    Note what this does and does not say. It does not say your therapist is against you. It says the field has a known blind spot that it does not systematically train out, so the burden of screening lands on you. That is unfair, and it is also the situation.

    What “weight-inclusive” means, and what it does not

    A weight-inclusive practitioner treats your body size as a fact about you, not as a diagnosis, a symptom, or a target. Concretely, that means:

    • Your weight is not assumed to be the cause of what brought you in, unless there is a specific reason to think so.
    • Weight loss is not offered as a therapeutic goal, a side benefit, or an unprompted suggestion.
    • Weight stigma is understood as a stressor with documented mental health effects, so your experiences of discrimination are treated as real events rather than as distorted thinking to be corrected.
    • Body size is treated as a diversity dimension in the same way as race, gender or sexuality: something the practitioner has thought about their own assumptions on.

    What it is not: it is not a programme, a method, or a school of therapy. Weight-inclusive practice is compatible with behavioural therapy, psychodynamic work, systemic therapy, and everything else. Nobody needs to abandon their method to stop weighing you.

    It is also not the same thing as a practice that advertises “obesity counselling” or “weight management support”. Those describe the opposite orientation: the body is the object of treatment. If a listing puts both labels on the same profile, believe the second one.

    If you want the longer version of the underlying framework, we covered it in Health at Every Size, explained. The medical equivalent of this search is in How to find a weight-neutral (HAES-aligned) doctor.

    The directories that exist, and what each actually does

    There are fewer than the internet suggests, and they do different jobs. It is worth knowing which.

    The ASDAH Health at Every Size Provider Listing (asdah.org/listing) is the closest thing to a screened register. Practitioners are vetted for alignment with the Health at Every Size principles through a set of questions, and depending on the score, ASDAH may additionally review their website and social media content. There is a public form for reporting a listed provider you believe is not aligned, and ASDAH states it does not keep the results of those investigations confidential. You can filter by profession, country, language, sliding scale, insurance, virtual or in-person, and by provider identity.

    Two honest limits. First, it is a membership directory: you have to be a paying ASDAH professional member to apply, which means absence from the list says nothing about a practitioner. ASDAH offers income-based fees and free membership for Black, Indigenous and People of Colour, but the gate exists. Second, ASDAH itself says listed providers only agree that they are appropriately trained and credentialed, and it explicitly encourages users to verify local licensing requirements themselves. Treat it as a good starting shortlist, not a certification.

    Inclusive Therapists (inclusivetherapists.com) does something different that is easy to confuse with the same thing. It lets you filter by the provider’s own identity, including “fat person”, and separately by specialty, including “fat liberation”. A fat therapist is not automatically a weight-inclusive one, and a thin therapist can be excellent at this. Both filters are useful; they answer different questions. Decide which one you actually care about before you search.

    EDRD Pro (edrdpro.com) is a directory of eating disorder professionals working from weight-inclusive models. It is weighted heavily towards dietitians rather than psychotherapists, so it is the right tool for the nutrition side of a care team and the wrong one if you are looking for a talking therapist.

    None of these certifies anyone. They narrow the field. The screening is still yours to do.

    When the directory is empty where you live

    This is the part most guides skip, and it is the situation for most of the world.

    We checked the ASDAH listing by country on 31 July 2026. For Germany it returned exactly one entry, and that person is a dietitian, not a therapist. Austria returned nothing. Switzerland returned nothing. The country dropdown offers around 45 countries; the listing itself is overwhelmingly United States, with Canada, the UK and Australia behind it.

    So for most people reading this outside North America, the directory route ends in about ninety seconds. That is not a reason to give up on the search. It means the search is done through general directories plus your own screening, and the screening questions below are the actual skill.

    Five questions that sort practitioners quickly

    You can ask these in a first appointment, in an initial phone call, or by email before booking. A practitioner who finds them reasonable is already telling you something; so is one who finds them hostile.

    1. “Do you weigh clients, and can I decline?” In talking therapy there is usually no clinical reason to weigh anyone. The answer you want is either “no” or “only if there is a specific reason, and yes, you can decline”. The answer that ends the conversation is a routine weigh-in you are expected to accept.

    2. “How do you work with a client who wants to lose weight, and with one who doesn’t?” This is the most informative question on the list, because it does not tell them which answer you are looking for. You are listening for whether they can describe working with someone who is not pursuing weight loss without treating that as denial, avoidance, or a lack of insight.

    3. “Have you had training on weight stigma or working with higher-weight clients?” Given the training gap above, “no, but I have read into it myself” is an honest and workable answer. “Yes, I did a course in obesity management” is a different answer than it sounds like; ask what the course taught.

    4. “If I tell you about being treated badly because of my body, what do you do with that?” You are checking whether discrimination gets handled as an event that happened or as a perception to be reframed. Both have a place in therapy, but the order matters, and it should start with believing you.

    5. “What would make you raise my weight when I have not raised it?” A clear answer here is a good sign in either direction. “I wouldn’t” is fine. “If it seemed connected to what you came in for, and I would ask first” is also fine. Vagueness is the warning.

    Red flags in a first session

    • Your weight is mentioned before your reason for coming.
    • You are asked about diets, eating or exercise when you came in about something unrelated.
    • Weight loss is described as something that would improve your mental health, without you raising it.
    • Your account of being discriminated against is reframed as sensitivity, as your interpretation, or as motivation to change your body.
    • The practitioner’s own discomfort with the topic becomes something you find yourself managing.

    One caveat on the second point: it is legitimate for a therapist to ask about eating, sleep and activity as part of a general intake, the same way they ask about alcohol. The flag is the follow-up, not the question.

    You are allowed to leave

    The most useful thing to know going in is that a first session is not a commitment. Fit is a clinical variable, not a nicety, and a practitioner who cannot see your body without narrating it is not a fit, regardless of how good their credentials are.

    Changing therapists after one session is not failure and it is not rudeness. It costs you one session. Staying with the wrong one costs considerably more, and the research above suggests it can cost you the accuracy of your own diagnosis.

    If what brings you to therapy is urgent, or if you are in crisis, use your local emergency or crisis service rather than continuing this search. Finding the right long-term fit is a project for a week when you are not in acute distress.

    The wider picture of what weight stigma does to mental health is in The mental weight of living in a fat body.

    Sources: Philip SR, Standen EC, Schueler J, Fields SA, Phelan SM. Weight bias in mental health settings: a scoping review. Front Psychiatry. 2025;16:1596625. doi:10.3389/fpsyt.2025.1596625. ASDAH Health at Every Size Provider Listing and listing FAQ, retrieved 31 July 2026. Inclusive Therapists provider directory, retrieved 31 July 2026. EDRD Pro directory, retrieved 31 July 2026.

  • What Is Fat Liberation Month? Origins, Dates, and How to Take Part

    What Is Fat Liberation Month? Origins, Dates, and How to Take Part

    Every August, a slice of the internet turns purple, loud, and celebratory under the hashtag #FatLiberationMonth. If you have run into it and wondered what exactly you were looking at, this is the explainer: where the month came from, who runs it, what happens during it, and how you can take part if you do not live in the United States.

    One thing up front, because it matters on this site: Fat Liberation Month is not a health campaign, not an awareness week about a disease, and not a before-and-after story. It is a celebration organised by fat people for fat people, and its stated premise is that fat people do not owe anyone an improvement plan.

    The short version

    Fat Liberation Month runs for the whole of August. It is organised by NAAFA, the National Association to Advance Fat Acceptance, which describes itself as the world’s longest-running organisation working on fat rights. August 2026 is the sixth annual edition.

    There is no membership requirement and no registration. NAAFA has explicitly invited anyone in the world to use the hashtag and to plan their own events.

    Where it came from

    The origin story is unusually well documented, because NAAFA wrote it down itself.

    In the autumn of 2020, Clark Beltran wrote an essay for the NAAFA blog about Latino Heritage Month. He reflected on what it meant to him, as a Mexican-American man, to have a national celebration of his ethnic heritage, and as a gay man to have Pride Month, but to have nothing comparable for his identity as a fat man. He asked where the equivalent celebration for people of size was.

    The essay circulated on NAAFA’s social media. In the discussion that followed, the activist and performer Juane Tango suggested that the fat community could simply hold such a celebration. By NAAFA’s own account, Tango did not charge NAAFA with organising it, and had made the suggestion before, along with the idea of a fat community flag.

    Darliene Howell, then NAAFA’s Chair, and Tigress Osborn, then Chair Elect, took the suggestion to the NAAFA Board. The Board handed it to its Future of NAAFA Committee, which worked out the details. The first Fat Liberation Month launched in May 2021.

    It moved almost immediately. After the first edition, NAAFA received feedback that May was a poor fit because it is Asian American and Pacific Islander Heritage Month, and the Board voted to shift the 2022 celebration to August. It has stayed in August since.

    The part most write-ups leave out

    NAAFA did not claim to have invented the idea, and published a list of people who got there first. That list is worth repeating, because a movement that credits its predecessors is doing something the wider wellness industry rarely bothers with:

    • Denarii Grace (@writersdelite) ran an online Fat Acceptance Month in 2019 and again in 2021.
    • Karabelo Makale used the hashtag #fatacceptancemonth on Instagram in 2019.
    • A Small Town Monarch (@femmina) began using #fatliberationmonth in January 2020, as NAAFA records it, “just out of exhaustion with how January usually is”, that is, out of exhaustion with the annual diet-resolution season.
    • Dr. Victoria Reuveni (@drvixenne) was, by NAAFA’s account, the first person to use #fatliberationmonth on Instagram, on 7 January 2020.
    • Luis Heredia argued for a Día Orgullo Gordo, a Fat Pride Day, in a 2017 editorial for the Spanish site Hora Jaén.

    The January detail is the interesting one. The hashtag started as a counterweight to New Year diet pressure. The organised version ended up in August, which means the calendar now has a celebration at the opposite end of the year from the season when the pressure is heaviest.

    Why NAAFA, and why this matters

    NAAFA’s own history explains the shape of the month. By its account, the organisation was founded in 1969 by Bill Fabrey, a young engineer in New York who was angry about how the world treated his wife, Joyce. He had read an article by Lew Louderback in the Saturday Evening Post about anti-fatness in US culture, copied it, and handed it out to everyone he knew. With Louderback’s help he gathered a small group and founded what was then called the National Association to Aid Fat Americans.

    A group of California feminists found NAAFA insufficiently radical and formed the Fat Underground. What NAAFA called fat acceptance, they called fat liberation. In 1973 they published the Fat Liberation Manifesto, which demanded equal rights for fat people in all areas of life and named the “reducing” industries as adversaries.

    That split is still audible in the name. “Fat Liberation Month” uses the more radical of the two vocabularies, run by the organisation that originally used the gentler one. The month is not asking for tolerance. It is asserting a right.

    If you want the longer version of that history, including the parts about queer and lesbian-feminist organising that carried the movement through its first decade, we covered it separately in Fat and Queer: The Shared History of Two Movements.

    What actually happens during the month

    The programme is mostly community events, run online so people can join from anywhere. The 2025 edition gives a fair picture of the format: a kick-off party, sessions on fat movement and chair-based exercise, fat sexuality, fat writing, a “Fat Spotlight” interview series, an annual trivia challenge, a wrap party, and a virtual auction that doubles as fundraising.

    The through-line is the absence of a health frame. Nobody is being taught to manage anything. That is the point of the format, not an oversight.

    Politics shows up too, though usually by coincidence of timing rather than design. Minneapolis amended its civil rights ordinance in 2025 to prohibit discrimination on the basis of height and weight, alongside housing status and justice-impacted status. The City Council passed the amendments unanimously on 1 May 2025, Mayor Jacob Frey signed them that same month, and they took effect on 1 August 2025, the first day of that year’s Fat Liberation Month. Reporting differs on how many US cities have such protections, so treat any specific count with caution; the Minneapolis dates come from the city itself.

    Where 2026 stands, as of the end of July

    NAAFA’s page for the sixth edition is live and confirms August 2026, but as of 30 July 2026 it carries no programme and no annual theme. There are donation and mailing-list links, and links to the archives of previous years, but no event list yet.

    Practically, that means two things. If you want to follow the official programme, watch naafa.org/flm2026 and NAAFA’s mailing list in the first week of August. And if you were waiting for a lead to follow, there is not one yet: anything happening in the first days of the month will come from individual communities rather than from a central schedule.

    How to take part from outside the US

    Fat Liberation Month is US-organised, and most of the scheduled events run on US time zones. That is a real limitation, not a detail to gloss over. But the month was deliberately built as an open format, and NAAFA has said in writing that it invited the whole world to use the hashtag and plan its own events. There is nothing to join and nothing to ask permission for.

    Some things that travel well:

    • Use the hashtag on the platforms you actually use. The point of an open hashtag is that it aggregates activity that no one organisation could have scheduled.
    • Do something local and small. A clothing swap in extended sizes, a reading group, a swim session, a meet-up. The 2025 programme was mostly this, at scale.
    • Attend online sessions where the time zone allows. Events on US Pacific time in the late afternoon land in the middle of the European night; US Central early evening is more workable.
    • Turn it into a deadline. An observance is a good excuse to do the thing you have been putting off: writing to a company about its size range, filing a complaint you drafted months ago, asking your employer’s HR whether its anti-discrimination policy names body size.

    What Germany does not have

    We looked for a German equivalent and did not find one: no established German-language observance, no comparable month, no umbrella organisation running one. If something exists that we missed, we would like to hear about it.

    The legal backdrop is part of the reason there is less to celebrate. The German General Equal Treatment Act (AGG) does not list body weight as a protected characteristic. A parliamentary motion to add it, among other characteristics, had its first reading in the Bundestag in June 2026 (Drucksache 21/4538), tabled by an opposition group; it is a proposal, not law. Until that changes, weight discrimination in Germany largely has to be argued through other channels. We set out what those are in When the World Is Not Built for You: Weight Discrimination and What You Can Do.

    The other date worth knowing

    If August passes you by, the second fixed point in the calendar is Weight Stigma Awareness Week, running 8 to 9 September 2026 with the theme “The Power of Fat Joy”. It is created and co-hosted by Dr Wendy Oliver-Pyatt of Within Health and Chevese Turner of The Body Equity Alliance.

    Worth knowing about the difference: Within Health is a commercial eating-disorder treatment provider. That does not make the week less useful, and the stated theme, visibility, belonging, and the right to live joyfully without apology, is squarely in the same tradition. But it is a different kind of organiser than a member-run advocacy organisation, and it is reasonable to keep that in view.

    The one-line summary

    August is Fat Liberation Month. It exists because a fat man asked in 2020 why there was no celebration for people like him, and enough people agreed to build one. There is no gatekeeper, no entry fee, and no improvement plan attached.

    Sources: NAAFA, “Fat Liberation Month 2026” (naafa.org/flm2026, retrieved 30 July 2026); NAAFA, “History of Fat Liberation Month” (naafa.org/2022-flm-history); NAAFA, “Fat Liberation Month 2025” (naafa.org/flm2025); NAAFA, “NAAFA’s Origin Story & Fat Activism History” (naafa.org/history); Weight Stigma Awareness Week 2026 (within-health.ce-go.com); Minneapolis civil rights ordinance amendments, effective 1 August 2025, as reported by Marketplace (1 August 2025) and multiple employment-law analyses; Deutscher Bundestag, Drucksache 21/4538, first reading June 2026.

  • Fat and Queer: The Shared History of Two Movements

    Fat and Queer: The Shared History of Two Movements

    Fat liberation is often told as a story about self-esteem. It wasn’t. In its first decade it was a small, angry, mostly lesbian-feminist political project, and the record of that is public, dated and citable. If you only know the movement through the body-positivity vocabulary of the last fifteen years, you are missing the half of it that was queer from the start.

    This is not a claim about who “owns” fat activism. It is a claim about where the documents came from.

    The record was written by the people who were in it

    In June 2010, at the NOLOSE gathering in Oakland, California, the British fat activist and sociologist Charlotte Cooper ran a workshop in which roughly fifty fat lesbians, dykes, bi women and trans people drew a shared timeline of their own movement on a roll of wallpaper. Cooper published it as a zine, A Queer and Trans Fat Activist Timeline, in 2011. She is explicit that it is not a definitive history: it is collective memory, sketchy and inconsistent by design, produced by a specific group in a specific room.

    Read as what it is, it is still remarkable. The entries run from a 1967 “Fat-In” in Central Park through four decades, and the queer entries are not occasional. A small anti-dieting group of dykes in San Francisco’s Castro in 1978. Shadow on a Tightrope, the 1983 anthology of women’s writing on fat oppression. The Fat Dykes Statement, published in 1989 in the British feminist journal Trouble & Strife. A Fat Dyke Float in the San Francisco parade in 1992. The zine FaT GiRL, 1994 to 1997. In 1997, a photograph of a fat woman on the cover of Lesbian Connection generating enough hostile mail to become a movement event in its own right, which is roughly how NOLOSE came to exist at the end of that decade. (Sources disagree on whether to date NOLOSE to 1998 or 1999; the timeline says 1999.)

    Cooper wrote the workshop proposal partly because she had watched this record get quietly de-queered: fat activism repackaged as a respectable message about how normal fat people really are, with the dykes edited out.

    A manifesto that named everyone except itself

    The founding document is easy to check. The Fat Liberation Manifesto was written in November 1973 by Judy Freespirit and Aldebaran and published by the Fat Underground in Los Angeles. It is one typed page, seven points, and it has aged strangely well. Point five names the “reducing industries” as the movement’s special enemies. Point three declares the struggle allied with other struggles “against classism, racism, sexism, ageism, financial exploitation, imperialism and the like.”

    Note what is not in that list. In 1973, in a document produced inside a radical-feminist milieu, homophobia goes unnamed even in the solidarity clause. The queerness of early fat liberation is in who was in the room, in the archives, in Sinister Wisdom and the lesbian press that circulated the Fat Underground’s position papers, not in the manifesto’s own self-description. That gap is part of the history too, and worth stating plainly rather than smoothing over.

    Freespirit died in San Francisco in September 2010, aged 74. Her personal papers are held at the June L. Mazer Lesbian Archives.

    Why the overlap is not a coincidence

    Two movements met here because they were fighting the same reflex.

    Both a fat body and a queer body get read as evidence about the person inside: as appetite not properly governed, as a private failure made publicly visible, as something that would be fine if it were only kept discreet. Both get offered the same deal, which is tolerance in exchange for minimising yourself. And both movements produced the same split in response, an assimilationist wing arguing we are just like you, and a wing arguing that the demand to be just like you is the problem.

    The sharpest contemporary statement of this is Da’Shaun L. Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness (North Atlantic Books, 2021), which won the 2022 Lambda Literary Award in Transgender Nonfiction. Harrison, who writes as a fat, Black, disabled, nonbinary trans author, argues that anti-fatness cannot be separated from anti-Blackness, and works through desirability politics, healthism and policing to make the case. It is a book about how bodies are sorted, not a book about bodies. Read it before quoting it; it deserves better than the one-line version.

    Where the overlap gets concrete: the clinic

    The history is not just history. It has a current address, and it is a surgical waiting list.

    Many fat trans people run into a body-weight cutoff when they seek gender-affirming surgery. It is worth being precise about where that cutoff comes from, because it is usually described as a medical standard and usually isn’t one.

    The World Professional Association for Transgender Health sets out criteria for gender-affirming surgical treatment in Version 8 of its Standards of Care: a sustained diagnosis of gender incongruence, capacity to consent, understanding of the effects on reproduction, exclusion of other causes, assessment of conditions that could affect the surgical outcome, and stability on hormone treatment where relevant. There is no body-mass threshold in that list. Hospitals that impose one say so themselves: Cleveland Clinic presents its BMI limits as requirements “in addition to the WPATH standards”.

    Germany works the same way from the other direction. Gender-affirming measures under statutory health insurance are assessed against a binding guideline issued for the GKV-Spitzenverband under § 282 SGB V, Geschlechtsangleichende Maßnahmen bei Transsexualismus gem. ICD-10, F64.0, in the version dated 31 August 2020. Its criteria concern diagnosis, suffering, therapeutic history and everyday experience. Searching the full text of that guideline for a weight or BMI criterion returns nothing, because there isn’t one.

    So where do the numbers come from? Individual hospitals. Cleveland Clinic is useful here precisely because it publishes its rules and is honest about their status. Its gender-affirming surgery page lists those BMI thresholds as its own pre-surgery requirements, in its own words. They vary by procedure: 35 or lower for vaginoplasty, vulvoplasty, breast augmentation and mastectomy; 32 or lower for metoidioplasty and phalloplasty; 40 or lower for hysterectomy; and no threshold at all listed for orchiectomy, facial feminization or voice feminization.

    Two things in that list are worth sitting with. First, the numbers are not consistent with each other, which tells you they encode surgical judgement about specific procedures rather than a general rule about fat bodies. Second, the clinic says its requirements “may be adjusted in order to optimize approval for surgical procedures”, that is, the threshold is partly a negotiation with insurers, not purely a clinical finding. The page also concedes that BMI “is not perfect” and is meant as a starting point for a conversation.

    That is a legitimate thing for a surgical unit to decide, document and defend. It is not a professional standard, and it should not be presented to a patient as one.

    The practical difference matters. “The standards forbid it” ends a conversation. “This hospital has set this policy” is a fact you can ask about, ask the reasoning for, and take to a different unit. Nothing in this article is advice about anyone’s body. It is a note about which door you are actually standing in front of. Our guides on what to do when a doctor blames everything on your weight and on finding a weight-neutral doctor go into how to run that conversation.

    Sometimes access is furniture

    One entry in Cooper’s timeline is smaller than the rest and hard to forget. In 1996, after a letter of complaint from Geleni Fontaine, the Callen-Lorde Community Health Center, New York City’s LGBT health clinic, put armless chairs in all of its waiting areas.

    That is the whole entry. No campaign, no legislation. Someone wrote a letter about the seating in a clinic that was already trying to serve people other institutions turned away, and the clinic changed the chairs. Most of what fat liberation and queer organising actually have in common looks like that: not a slogan, but the discovery that a room can be built to exclude you without anyone at the door having to say so.

    What this history is good for

    Movements that forget their own beginnings repeat the arguments they already won. Fat liberation began as a coalition politics, written down as such in 1973, carried through three decades largely by queer women and later by trans and nonbinary activists, and archived by people who understood that archives are how a small movement survives being forgotten.

    Knowing that changes what “fat acceptance” is allowed to mean. It was never a request to be found acceptable.

    Sources: Charlotte Cooper, A Queer and Trans Fat Activist Timeline (zine, 2011, CC BY-NC-ND); Fat Liberation Manifesto, Judy Freespirit and Aldebaran, November 1973, via the Fat Liberation Archive; Lambda Literary tribute to Judy Freespirit, September 2010; Da’Shaun L. Harrison, Belly of the Beast, North Atlantic Books, 2021; WPATH Standards of Care 8 surgical criteria; Medizinischer Dienst, Begutachtungsanleitung “Geschlechtsangleichende Maßnahmen bei Transsexualismus”, 31 August 2020; Cleveland Clinic gender-affirming surgery scheduling page.

  • Flying While Fat: Airline Seat Policies, Seatbelt Extenders, and Your Right to a Second Seat

    Flying While Fat: Airline Seat Policies, Seatbelt Extenders, and Your Right to a Second Seat

    Flying while fat comes with a research project attached: every airline has a different rule for what happens if you don’t fit into a standard economy seat, and almost none of them make that rule easy to find before you’ve already paid for a ticket. This guide pulls together the actual policies, verified against each airline’s own documentation, plus the one binding legal precedent that exists anywhere in the world for a second seat at no extra cost.

    This is a service piece, not a verdict on any airline’s decency. The point is to know what you’re walking into before you’re standing at a gate.

    The basics: armrest, seatbelt, and who decides

    Every policy in this article comes down to the same two tests, phrased slightly differently by each airline:

    • The armrest test. If the armrest between two seats cannot be lowered because your body is in the way, or if your body extends past it into the neighboring seat, most airlines classify that as needing a second seat.
    • The seatbelt test. Standard economy seatbelts run about 40 to 44 inches (102–112 cm) fully extended, depending on aircraft and airline. If that doesn’t close, you need an extension. Every airline operating in the US, UK and EU is legally required to carry seatbelt extenders on board and provide them free of charge — this is a safety requirement, not a courtesy, and asking for one is not optional information you owe anyone.

    Who makes the call, and when, is where airlines diverge sharply.

    Airline by airline

    Southwest Airlines (US)

    Southwest has run some version of a “Customer of Size” accommodation for more than 30 years, and it went through a very public back-and-forth in 2026. On 27 January 2026, Southwest tightened the policy to require pre-purchasing a second seat as part of its move to assigned seating. After weeks of passenger complaints and public criticism, the airline reversed course by late May 2026.

    The current policy, confirmed directly on Southwest’s help center as of this writing:

    • The armrest is the official boundary between seats.
    • Booking two seats in advance is “strongly recommended” to guarantee adjacent seating, and that second seat is refundable after travel if the flight departed with at least one open seat.
    • If you didn’t book ahead and it turns out you need the space, Southwest will give you a complimentary second seat at the gate — but only if adjacent seats are actually available. If the flight is full, you get rebooked, not squeezed in.
    • One seatbelt extension per passenger, provided by Southwest, not usable in an exit row.

    Southwest remains the only US major with a no-cost path built into the everyday policy, not just an emergency workaround.

    American Airlines (US)

    American has no free accommodation. If you need more space, you buy a second seat at 100% of the adult fare (plus taxes, minus passenger facility charges), booked in the same reservation as “EXST.” There’s no cap on how many extra seats you can buy. If you show up without having booked ahead, a gate agent will try to find two adjacent seats — and if that means a higher fare class, you pay the difference. (Source: American’s internal Extra Seat Procedures documentation, updated November 2025.)

    Delta Air Lines (US)

    Delta’s language is softer but the mechanics are similar: if you’ll encroach into the next seat or can’t lower the armrest, you’re “encouraged” to buy an extra seat in advance at the same fare, or upgrade to Premium Select, First, or Delta One. If you don’t, and the flight is full, you get rebooked. Delta does not refund extra-seat purchases on nonrefundable fares — a real difference from Southwest’s refund policy.

    United Airlines (US)

    United requires passengers who can’t fit in one seat, buckle the seatbelt (including with a 25-inch/64 cm extender), or lower the armrest to either pay for an extra seat or be rebooked. United first tries to reseat you next to an empty seat elsewhere on the plane at no charge before asking you to pay — the free option exists, but only when the flight has spare capacity.

    British Airways (UK)

    BA requires a second seat when a passenger can’t lower the armrest or encroaches into the neighboring seat; this must be booked at least 48 hours ahead through the airline or a travel agent, not online, and is charged at the standard or lowest applicable fare. Seatbelt extenders are carried on every aircraft and provided free on request. We could not verify specific weight or width thresholds sometimes quoted for BA (such as a fixed kilogram or centimeter cutoff) against BA’s own published policy, so we’re not repeating those numbers here — the airline’s stated criteria are the armrest and seatbelt fit, not a published measurement.

    Ryanair (UK/EU budget)

    Ryanair sells a second seat as a general “comfort” option, not a size-specific accommodation: you book two full-fare tickets, with the second passenger entered as “EXTRA COMFORT SEAT.” There’s no separate size policy, no reduced fare for the second seat, and no baggage allowance attached to it. Functionally this is the least accommodating option on this list — full price, no size-based framing, no free path.

    Lufthansa, Eurowings, Condor (Germany)

    None of the three has a formal published size policy. In practice, check-in staff try to find an empty neighboring seat on a case-by-case basis, and none of the three charges extra for it when they can. That’s more flexible day-to-day than the US majors, but it also means there’s nothing to point to in writing if a specific flight or a specific agent doesn’t accommodate you — no policy means no guarantee, in either direction.

    The one legal right that actually exists: Canada

    In January 2008, the Canadian Transportation Agency ruled that Air Canada, Air Canada Jazz and WestJet must offer “one person, one fare” on domestic flights to passengers who are, in the Agency’s language, “functionally disabled by obesity” and need a second seat, as well as to passengers with disabilities travelling with a required attendant. The airlines appealed; the Supreme Court of Canada declined to hear the case, so the ruling stands as binding precedent in Canada.

    Two limits matter: it applies to domestic Canadian flights only, and it requires documentation of a disability-level need, not simply “I’d be more comfortable.” It has never been adopted in the US, the UK, or the EU. There is no equivalent minimum seat width or second-seat right anywhere in EU or German air passenger law — this is a gap, not an oversight anyone is currently required to close.

    Booking tips that follow directly from the policies above

    • Book the second seat when you book the first one, wherever a second-seat option exists (Southwest, American, Delta, United, BA, Ryanair all support this at booking). Showing up and hoping costs you the airline’s discretion, not your right.
    • Ask about refund policy before you pay. Southwest refunds; Delta does not on nonrefundable fares; check before assuming either way.
    • A seatbelt extender is not a downgrade or a favor. It’s required safety equipment every airline listed here must carry and provide free. You don’t need to justify asking for one.
    • If flying Lufthansa, Eurowings or Condor, call ahead rather than relying on the gate, since there’s no written policy to invoke if a specific flight is full.
    • Know your route. If you’re flying domestically within Canada, the one-person-one-fare right may apply to you if you can document a qualifying disability — worth investigating before you fly, not after a bad experience.

    What this guide doesn’t do

    It doesn’t rank airlines by kindness, and it doesn’t tell you your body is the problem here — a 17-inch economy seat is a design decision by the airline, not a fact about you. What it does is give you the actual rules, checked against each airline’s own published documentation where one exists, so you can plan a trip instead of gambling on one.

    Sources

    • Southwest Airlines, “What is your policy for Customers of size?” — support.southwest.com (fetched live, 28 July 2026)
    • American Airlines, “Extra Seat Procedures” — saleslink.aa.com (updated November 2025)
    • Delta Air Lines, “Extra Seat – Personal Comfort” — pro.delta.com
    • Ryanair, “Can I buy an extra seat for comfort?” — help.ryanair.com
    • Canadian Transportation Agency ruling, January 2008, and the Supreme Court of Canada’s 2009 refusal to hear the airlines’ appeal
    • United Airlines and British Airways policies confirmed via independent secondary reporting where primary airline pages were not directly fetchable; unverifiable numeric thresholds (see British Airways section) were deliberately omitted
  • How to Measure Yourself for Plus-Size Fit (and Actually Trust the Size Chart)

    How to Measure Yourself for Plus-Size Fit (and Actually Trust the Size Chart)

    Online shopping for plus-size clothes fails for a boring reason more often than any other: people order by the size they “are” instead of the measurements they have. Labels lie, brands disagree with each other, and a size 20 in one shop is a 24 in the next. The fix is unglamorous and completely reliable — measure yourself once, write the numbers down, and buy from the chart instead of the label. Here is how to do it properly.

    What you need

    One soft tape measure (the flexible fabric kind used for sewing, not a metal builder’s tape). If you don’t own one, a piece of string plus a ruler works: wrap, mark, then measure the string flat. Wear thin clothing or underwear, because measuring over a chunky jumper adds phantom centimetres. If you can, ask someone to help with the back measurements; it’s hard to keep the tape level on yourself.

    The measurements that actually matter

    Keep the tape snug but not tight — it should sit flat against you without digging in. Stand relaxed and breathe normally. Note every number in both centimetres and inches, since brands use different units.

    Bust / chest

    Wrap the tape around the fullest part of your bust, usually across the nipples, and straight across your back. Keep it parallel to the floor. Wear the bra you’d normally wear under that garment, because it changes the number.

    Waist

    Find your natural waist, the narrowest part of your torso, roughly level with your belly button or slightly above. If you can’t see a narrowest point, bend to one side; the crease that forms is your natural waist. Don’t suck in.

    Hips

    Measure around the fullest part of your hips and bottom, feet together. For fitted skirts and trousers, also take your “high hip” — around the upper hip bones, about 8 cm below the waist — because that is where a lot of plus-size trousers actually catch.

    For trousers, add inseam and rise

    Inseam: measure from the crotch seam down to where you want the hem, along the inside of the leg, using a pair of trousers that already fit well laid flat. Rise: on those same trousers, measure from the crotch seam up to the top of the waistband, front and back. Rise is the number that decides whether trousers sit where you want them or fight you all day.

    How to read a size chart without getting burned

    Now the part that saves you the return postage. Every reputable brand publishes a size chart with actual body measurements. Ignore the size name and match your numbers to the chart of the specific brand you are buying from — never assume your size carries over.

    • Match your largest relevant measurement first. If your hips land in a 24 but your waist in a 22, order the 24 and, if needed, take in the waist. It is far easier to nip in than to let out.
    • Check whether the chart lists body measurements or garment measurements. Body measurements are your size; garment measurements already include ease and run bigger. If it doesn’t say, assume body measurements.
    • Look for the ease note. A woven, non-stretch fabric needs a few centimetres of wiggle room to move and sit in; a stretchy jersey can sit close to your exact numbers.
    • When you are between sizes, size up in wovens, and by your priority area in knits. You can always tailor a slightly loose woven; a too-tight one is just uncomfortable.

    A note on international sizes

    UK, US, EU and German sizes do not line up, and conversion tables are only rough guides. A German 52 is not reliably a UK 24. This is exactly why the measurements matter more than the label: centimetres are the same everywhere, dress-size numbers are not. Keep your measurement card in your phone and re-check it against each brand’s own chart.

    The point

    None of this is about shrinking to fit a garment. It is the opposite: it is how you make garments answer to your body instead of the other way round. Clothes that fit are a right, not a reward — and the fastest route to them is a tape measure and five minutes, not a smaller size.

    Fatosphere holds one red line: we do not promote diet or weight-loss products. This is a fit guide for the body you have.

  • Where Fat Hatred Comes From: The Racial History Behind the “Thin Ideal”

    Where Fat Hatred Comes From: The Racial History Behind the “Thin Ideal”

    Most people assume the thin ideal is timeless — that humans have always admired slim bodies and worried about fat ones. They haven’t. The idea that a slender body signals health, discipline, and worth is surprisingly recent, and its history is far uglier than a story about “wellness.” A growing body of scholarship argues that modern fat hatred was built, in large part, out of anti-Black racism. It’s worth understanding where that argument comes from, what it explains, and where it’s still debated.

    The core argument

    The most influential version of this history is Sabrina Strings’ Fearing the Black Body: The Racial Origins of Fat Phobia (NYU Press, 2019). Strings, a sociologist, traces the Western fear of fatness from the sixteenth century to today, weaving together art, philosophy, science, and religion. Her claim is not that no one anywhere ever disliked a fat body before. It’s more specific and more damning: the particular idea that thinness equals beauty, morality, and racial superiority took shape alongside the transatlantic slave trade.

    As Europeans built a system that needed to justify enslaving African people, Strings argues, they increasingly coded fatness as “African,” excessive, and lacking self-control — and thinness as “European,” refined, and rational. Renaissance art that once celebrated round, abundant bodies gave way to an aesthetic of restraint. Protestant moralism folded appetite into sin. Then nineteenth-century race science dressed the whole prejudice in the language of medicine. By the time the modern diet was invented, “managing” the body had become a way of performing whiteness and respectability.

    Da’Shaun L. Harrison pushes the argument into the present in Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness (North Atlantic Books, 2021). Harrison connects anti-fatness to policing and state violence, noting that several Black people killed by US police — Eric Garner, Mike Brown, Tamir Rice — shared not only Blackness but larger bodies, and that fatness marks a body as threatening and “criminal” in the cultural imagination. Both authors draw on the earlier work of Black feminist thinkers like bell hooks and Patricia Hill Collins, who long argued that beauty standards are never just about looks — they’re about power.

    Why this matters, even if you’re not American

    It would be easy to read this as a US-specific story. It isn’t. The thin ideal was exported globally through the same colonial and commercial channels that spread everything else — fashion, film, medicine, advertising. In Germany and across Europe, the “respectable body” was defined against colonial others just as it was in the Anglo-American world. When we treat fatphobia as neutral health advice, we quietly inherit a value system that was never neutral to begin with. Naming its origins doesn’t make the discrimination worse; it makes it legible.

    It also reframes a debate we cover constantly. When today’s discourse treats weight-loss injections as pure progress, or a “return” to thinness as simply good taste coming back, this history is the missing context: the thin ideal isn’t a natural baseline we drifted from. It’s a manufactured standard with a specific, traceable, and racialized past.

    Where the argument is contested

    Good editorial practice means saying clearly: this is a powerful thesis, not a closed case. Historians of the body point out that suspicion of fatness has older and multiple roots too — Greco-Roman ideals of moderation, Christian teachings on gluttony as one of the deadly sins, class anxieties about excess. Critics of the strongest “racial origins” framing argue that Strings describes a real and important strand of the story rather than the single cause of all fat stigma everywhere.

    The honest synthesis is this: fat stigma is over-determined — many forces fed it. But the specific modern Western package, the one that fuses thinness with health, virtue, and status and then sells it back to us as science, is inseparable from the history of race. You can hold both truths at once. Doing so is more persuasive than pretending the case is simpler than it is.

    What to do with this

    Understanding the roots of anti-fatness isn’t an academic luxury. It changes what you do with the guilt. If the voice telling you your body is a moral failure is the echo of a colonial hierarchy, then “just lose weight” stops sounding like health advice and starts sounding like what it is: pressure to perform a standard that was rigged from the start. That doesn’t instantly free anyone. But it moves the problem out of your body and into the history that put it there — which is exactly where it belongs.

    For readers who want to go deeper, both books are worth reading in full: Strings for the long historical arc, Harrison for the sharp contemporary politics.

    The takeaway

    The standard you’ve been measured against was built, not discovered.

    The thin ideal is not ancient, universal, or innocent. The best current scholarship traces its modern form to the machinery of racism and colonialism — a claim that is influential, well-argued, and still actively debated at the edges. Either way, the practical lesson holds: the standard you’ve been measured against was built, not discovered. Knowing that is the first step to refusing it.

    Fatosphere holds one red line: we do not promote diet or weight-loss products. This article reflects that commitment.