Happy Re-birthday: Weight Loss

Surgery and the New Me

KAREN THROSBY
Rising obesity rates globally are widely perceived as signalling a public health
crisis of epidemic proportions and against which war must be waged through
the disciplining of bodies at the level of populations and the individual. In the
UK, this has taken the form of a wide panoply of proposed measures, initiatives
and screening programmes, ranging from the weighing of children in school and
banning the advertising of junk food to children through to pharmaceutical and
surgical interventions (House of Commons Health Committee, 2004; NAO,
2001; Ofcom, 2006). It is this latter weight loss surgery (WLS) that provides
the focus for this article.
WLS refers to a group of surgical interventions which aim to limit the bodys
ability to consume and absorb food through the reduction of stomach capacity
and/or intestinal length.
1
It is generally regarded as a treatment of last resort for
those experiencing signicant and intractable obesity, and one which carries
signicant risks. For example, a US review of WLS (Buchwald et al., 2004: 1729)
found operative mortality rates ranging from 0.1 percent to 1.1 percent, depend-
ing on the specic procedure; other complications and chronic side effects
include infection, malnutrition, internal bleeding, vomiting, diarrhoea, and other
intestinal and digestive problems (e.g. Ackerman, 1999; Buchwald et al., 2004).
Body & Society

2008 SAGE Publications (Los Angeles, London, New Delhi and Singapore),
Vol. 14(1): 117133
DOI: 10.1177/1357034X07087534
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Consequently, even though many reach a healthy weight, for some, this is at the
cost of ill-health. This tension problematizes the presumed positive relationship
between health and slimness that governs the war on obesity, and has been high-
lighted within critical obesity studies in relation to the full range of weight loss
interventions (see, for example, Aphramor, 2005; Campos, 2004; Gard and Wright,
2005; Monaghan, 2005). However, it is also the case that WLS (or obesity surgery,
as it is also known) can produce signicant and sustained weight loss which can
transform health status and quality of life, and has been associated with positive
psychosocial outcomes (e.g. Bocchieri et al., 2002; Buchwald et al., 2004; Ogden
et al., 2005). According to a survey of UK bariatric surgeons conducted in 2005
by the British Obesity Surgery Patient Association (BOSPA), 4341 surgeries were
expected to be performed in the UK that year almost double the number of the
previous year (2287). Less than half of these received NHS funding,
2
and demand
continues to signicantly outstrip supply, with BOSPA receiving 30004000
inquiries every month from people looking for information about surgery or
asking for advice about obtaining funding (BOSPA, 2005).
The title of this article happy re-birthday is taken from the online
discussion forums of one of the very few UK organizations that provides support
and information for those seeking, undergoing and living with WLS. In many of
the forum postings, the surgery date is referred to by members as their re-birth
date, and members are congratulated on having undergone surgery with the
words happy re-birthday (see also Bocchieri et al., 2002; Ogden et al., 2006: 287;
Salant and Santry, 2006: 2450). The rhetoric of re-birth is also seized upon in the
marketing of the rapidly proliferating range of WLS products and services. For
example, in its winter 2005 issue, the US magazine Weight Loss Surgery Lifestyle
carries a full-page ad for a Weight Loss Surgery Success Kit an inspirational
CD and book offering support, advice and encouragement post-surgery. The
surgery is described in the ad as an opportunity to be re-born, and against a
backdrop image of a white dove being released from a pair of hands, the legend
written across the middle of the page reads: Your life, take two. Drawing on
interview data from people who have had, or are waiting to have, WLS, this
article explores what is signied by this discourse of re-birth in the context of
WLS, and asks what material and discursive work is required to support the
identity of the re-born post-surgical new me.
The discourse of re-born new me is a familiar trope of narratives of norma-
tive bodily transformation: for example, in the context of cosmetic surgery (Davis,
1995; Gilman, 1998, 1999; Gimlin, 2000, 2002), or gender reassignment surgery
(Hausman, 1995; Prosser, 1998). Similarly, magazine stories of dieting success
strategically employ before and after photographs to illustrate the new me as
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fundamentally distinct from the previously fat self, and the reveal segment of
makeover TV shows after a period of separation from friends and family relies
for its effects on the newness of the modied body (Palmer, 2004; Weber, 2005).
Fundamental to these accounts, and also to those of WLS, is the framing of the
re-born new me, not as an entirely novel entity but as having been rediscovered
and restored: the new me is also the real me. Central to this construction is the
concept of the pre-transformation body as discordant with the true self; of the
true self as trapped in the wrong body. This is most obviously evident in trans-
gender narratives, but also in the context of cosmetic surgery, where a particular
body part or feature is experienced as not aligned with the self. In the context of
weight management, the concept of the body and self as misaligned, and speci-
cally, of the thin person trapped inside a fat body, resonates easily with the visual
logic of weight loss. As one of the contributors to the online discussion forums,
with a note of self-deprecating irony, signs off his posts: Theres a tall, slim,
good-looking guy in here just waiting to get out. Similarly, Barbara Thompson
(2003) subtitled her self-published account of WLS nding the thin person
hiding inside you.
However, the restorative discourse of nding the real me is highly contin-
gent and slippery, particularly in the context of weight loss, which is deeply
entrenched within a potent nexus of moral prescriptions for the care of the self
through the meticulous surveillance and disciplining of the body (Bartky, 1991;
Bordo, 1993; Heyes, 2006). It is these prescriptions that underpin the easy attri-
bution of negative traits, such as laziness and poor self-control, to those who
are overweight (Murray, 2005; Throsby, 2007), and which bestow the means of
achieving weight loss with as much moral signicance as the end of slimness
itself. It is in this way that the body becomes a site for cheating; that is, for
taking the easy option or a short cut, and a presumed unwillingness to accept
responsibility for the normatively prescribed work of an ongoing regimen of diet
and exercise. Surgical technologies of weight loss leave individuals particularly
vulnerable to these accusations, since they appear to take the need for control
away from the patient. For example, the daughter of one of the participants in
my study, when confronted with her mothers signicant post-surgical weight
loss, argued that its not really an achievement the same as if it had been done
normally, adding, youve just had your insides cut up and it doesnt let you eat.
Anyone could do it [lose weight]. Successful weight loss outside of the norma-
tive rubric of diet and exercise, therefore, risks rendering the new (real) me
always potentially inauthentic.
In thinking about what constitutes the new me of WLS, it is important to
remember that, unlike other surgical technologies of normative body modication
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such as cosmetic surgery or gender reassignment, the immediately post-surgical
body in WLS is visibly unchanged (with the exception of surgical scarring).
Nevertheless, it is the moment of surgery itself that the discussion forum
members nominate as their re-birthday. In this article, I want to argue that
rather than referring directly to the visibly transformed body, the discourse of
re-birth instead signals the reconguration of the self as a disciplined subject,
who is able to exercise control and restraint over consumption, and who is willing
(and able) to take responsibility for the body. This enables those who have under-
gone surgery to repudiate not only the negative representations of the fat as lazy
and lacking self-control, but also to resist the construction of WLS as cheating.
However, this identity claim, I argue, is difcult to sustain consistently, and
requires the acquisition not only of very familiar disciplinary techniques of weight
management, but also new techniques, oriented towards the normalization of the
post-WLS body, that are both enabling and constraining.
Following a brief methodological discussion of the data upon which this
analysis is based, the remainder of the article is divided into three parts. The rst
section discusses the ways in which the participants constructed the decision to
have surgery as exemplifying taking action in relation to their weight. From this
perspective, they can be seen as opting in to the work of weight management
(rather than dodging it), and as positioning themselves as subjects in the war on
obesity, rather than its vilied objects. The second section discusses the ways in
which the participants identied WLS as an enabling technology which allows
them to exercise the normatively prescribed vigilance over diet that had previ-
ously eluded them. This, I argue, works to normalizing effect, minimizing the
differences between WLS and other weight loss technologies and techniques. The
third section discusses the problems in sustaining this normalizing discourse in
the context of the unpredictable ways in which the surgery becomes visible to
others, and the difculties that this visibility generates in controlling how the
post-WLS body is read by others. This, I argue, generates new forms of bodily
vigilance and self-surveillance that are particular to WLS, and which have to be
incorporated into the disciplinary work of producing and maintaining the re-
born new me.
Methodology
The interviews on which this article primarily draws were conducted in 20056
with people who have been (and in many cases, still are) medically categorized as
morbidly obese, and who had either had, or were waiting to have, WLS. In total,
I conducted interviews across England and Scotland with 35 people (6 men and
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29 women), all of whom had either undergone, or in a few cases, were waiting to
undergo, WLS.
3
The gender distribution of the sample reects the profoundly
gendered nature of WLS, with over 80 percent of all surgeries performed on
women (Ellis et al., 2006). In some cases, family members joined in the inter-
views, and I also conducted one focus group at the beginning of the project with
members of a WLS support group in the north of England. The majority of the
participants were recruited through the website discussion forums of one of the
only organizations in the UK offering information and support for those seeking,
undergoing and living with WLS and an additional few were recruited by word
of mouth, via friends and colleagues. The interviews were transcribed and
analysed using discourse analysis. Over the course of the project, I have also been
a regular reader of the discussion forums, which are a valuable source of back-
ground information, but these have not been the subject of systematic study.
One of the features of the organization and its discussion forums is its very
positive approach to WLS and this is reected in the interviews, which offer only
a partial account of the experience of WLS. Indeed, it could be argued that the
happy re-birthday discourse is dened by a spirit of optimism about the new
future, and that this is a dening characteristic of the discussion forums, which
are populated primarily by those either seeking treatment, or in the celebratory
period of dramatic post-surgical weight loss. It is also relatively rare to encounter
a member who has experienced treatment failure, especially in terms of regain-
ing signicant amounts of lost weight several years after the surgery. Instead,
outside of those who are publicly recommitting to weight loss, either through
renewed discipline or, in some cases, further surgeries, those having negative
experiences of surgery (including both serious complications and weight regain)
tend to drop out of the discussion forums and are consequently not represented
here. This remains an area where further research is required to give a fuller picture
of the experience of WLS, but is beyond the scope of this particular project.
In the writing up of the research, I have chosen not to provide any information
about the weights of individuals discussed in the article, since I do not wish to add
to the enfreakment of those who have become extremely large that is prevalent
in contemporary culture. Instead, I consider specic weights to be less important
than the way in which body size is experienced and made sense of by individuals.
In addition, for reasons of anonymity, pseudonyms have been used throughout.
Im Not Going to Take This Shit Any More
One of the primary strategies through which the new me of WLS is signalled
is through identication of surgery as a form of proactive, and often resistant,
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action (for example, in relation to doctors or family members). From this perspec-
tive, even the decision to undergo surgery can be seen as the beginning of the
new me:
I woke up the next day and said, Im not going to take this shit any more. You know, youve
done something to get yourself sorted. [. . .] You know, the speed that I got my condence back
was incredible. (Lyn)
Lyn, a focus group participant, had experienced signicant resistance from her
doctors to her having WLS because her extremely large size made the surgery
very risky. She spoke frustratedly about how they would just send her away with
instructions to use a smaller plate and to eat more salad a comment that
produced resigned nods of recognition from the rest of the group. This is the
shit that she is no longer willing to take, and her decision to undergo surgery
marks, for her, a transition out of passivity and into action and responsibility. But
signicantly, in Lyns case, this is articulated specically as a moment of restora-
tion she got her condence back, positioning the years of soul-destroyingly
ineffective diets as the deviation from the norm, rather than the decision to have
surgery. While this is expressed by Lyn as a form of resistance (against her
doctors advice), it can also be seen as a moment of conformity, and it is a far cry,
for example, from the resistant rhetoric of the size acceptance movement (e.g.
Wann, 1998). However, Lyns decision to undergo surgery cannot be viewed only
in terms of submission, since she is rejecting her doctors advice and the morally
privileged weight loss strategies of diet and exercise alone. From a Foucauldian
perspective, therefore, this reects the inseparability of power and resistance
(Foucault, 1979: 95), and highlights her ambiguous and contradictory position as
both the object of the war on obesity and its newly dedicated subject.
The long-term ineffectiveness of diets, particularly among those experiencing
signicant levels of obesity, is widely recognized, and many have argued that
unsuccessful and repeated dieting is a source of psychological and physical harm
(Berg, 1999; Campos, 2004; Sarlio-Lahteenkorva, 1998; Wann, 1998). This view
was endorsed by many of the participants, who cited their long histories of yo-yo
dieting as evidence of their intrinsic and biologically rooted inability to lose weight
without surgical intervention (Ogden et al., 2003; Throsby, 2007). The social
intelligibility of the argument that diets dont work enables those undergoing
WLS to constitute surgery not as a means of opting out from the work of losing
weight, but, rather, as a decisive move towards a qualitatively different kind of
intervention that is proportionate to the problems that they face.
While Lyn experiences her decision in terms of resistance, the decision to get
yourself sorted is entirely concordant with the dominant discourses of individual
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responsibility and taking control in relation to body size, and embraces the care
of the self not only as an individual matter, but also as a necessary condition of
effective citizenship and relationships (Heyes, 2006: 139). Exemplifying this
sentiment, the then-UK prime minister, Tony Blair, in a speech on healthy living,
described the costs associated with obesity as a collective price for the failure
to take shared responsibility (2006). Many of the participants mobilized this
discourse directly in their accounts as a means of positioning their surgery as a
form of social participation: for example, by highlighting future reduced costs in
health care and benets, and emphasizing their ability to be better parents and
providers, post-surgery. This enables them to actively resist representations of
those undergoing surgery as lacking in sufcient discipline to exercise control
over the body through the redenition of surgery as the act of taking responsi-
bility, rather than abnegating it, constituting the parallel enactment of both
conformity and resistance.
Dieting Like a Normal Person
The discourse of taking decisive action, and therefore opting wholeheartedly in to
the war on obesity, relies for its effect on the relatively dramatic nature of that
action. However, this also risks reinforcing the construction of WLS as an extra-
ordinary measure, which mediates against the normalization of the post-surgical
new me in ways which challenge its authenticity. In medical terms, normality
in body size is straightforwardly dened as having a BMI of 18.524.9 km/m
2
.
One website participant, for example, includes a countdown to normality in the
signature to her posts 13 lbs to go to NORMALITY and those reaching
their goal weights post delightedly that they are nally normal, enjoying the
pun between the medical categorization and the words more everyday usage. But
the category of normal is never only about body size and its medical categoriz-
ation. Fiona, for example, saw the post-surgical body as free to dene its own
normality:
The window of opportunity is basically your body deciding the weight its going to be. You
cant tell your body. Your body will decide the weight its going to be. And if you then want
to lose weight after that, you then have to diet like a normal person. You then become normal
after your window of opportunity. Even though, clinically, youll still be overweight, obese,
whatever. But youre normal then, for your body.
The window of opportunity refers to the one- to two-year period post-surgery
when weight loss occurs, with surgery here constructed as simply allowing the
body to be its authentic self. This is concordant with contemporary norms of
listening to your body and doing whats right for you in relation to the care
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of the self. But signicantly, while Fiona insists that the body decides, dieting
like a normal person is also a key feature of being normal for your body. This
makes sense in the contemporary social and cultural context where the body is
constantly to be worked upon and is never to be left to its own devices, and high-
lights the tension between the competing socially prevalent exhortations to both
listen to the body and to contain and control it. From this perspective, WLS is
constructed not as a resolution in itself, but as a rst step, or tool: a construc-
tion which leaves the work of weight loss with the individual, not the surgery.
As the founder of the organization noted in a written account of his experiences
of WLS:
Life at two years out is a challenge. As for most people, maintaining the energy intake output
equation whilst balancing a busy life is difcult. Now I am at least in with a chance to take
part. (personal communication)
Surgery, therefore, while constituting an extraordinary measure, is constructed
here as a means of achieving ordinariness that is, it enables the individual to
work at exercising the normatively determined self-surveillance and discipline of
the body.
By being able to locate his ongoing difculties with weight management along-
side those of most people, he is able to both normalize the post-surgical body,
and minimize the role of surgery, relative to his own body work of diet and
exercise, in the production of the post-surgical self.
The acceptance of the work of dieting like a normal person exemplies the
production of the docile body (Foucault, 1977), which requires not only the
self-subjection of the body to discipline and control down to the smallest detail
(Bartky, 1991; Bordo, 1993), but also the acquisition of new skills and capacities
through which those normative behaviours can be achieved (Heyes, 2006; Sawicki,
1991). As one of Ogden et al.s participants, Emma, states: Its about learning how
to eat from scratch and its a new start for me (2006: 286). Immediately post-
surgery, this is a very literal process, as people slowly progress from liquids to
soft mashed and blended foods, before carefully introducing solids a parody of
the weaning of infants that gives literal endorsement to the metaphor of re-birth.
Even once they are eating solid food, they have to learn to eat very small portions,
and eat very slowly and chew thoroughly to avoid food getting stuck in the
reduced stomach pouch, and to avoid drinking while eating. They also have to
develop a new relationship to food, often after years of yo-yo dieting. As Susan
observed: I dont want to spend the rest of my life feeling obsessed. I want to
eat what everyone eats [. . .] Ive got a family. I want to be able to sit down with
them for meals. Susans desire reects years of obsessive dieting, often involving
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the consumption of diet shakes, meal replacements or following restrictive food
plans, with obesity and her strong desire to be freed from it forcing the separ-
ation of herself from the food-life of the family (see also Sarlio-Lahteenkorva,
1998). The family meal is a potent symbol of happy family life (Lupton, 1996:
ch. 2; Murcott, 1997) and, anticipating her upcoming surgery, Susan longed for a
more normal, less anxious and tense relationship with food that would enable
her to engage more fully with the family a sentiment which recurs repeatedly
across the interviews (see also Ogden et al., 2006). This also reects more broadly
the motivating desires of many of the participants to be able to participate socially
as parents, partners, spouses, providers, friends and colleagues. However, as the
nal section of this article demonstrates, the surgery can make eating what
everyone eats very difcult and, even though the surgery prevents overeating,
many of the participants in this study still found themselves cooking separate
meals for themselves, or struggling to eat socially in case they needed to be sick.
In an article in the magazine Weight Loss Surgery Lifestyles, this new sense of
control over food (rather than being controlled by it) that Susan desires is articu-
lated explicitly in terms of authenticity and restoration in the articles headline:
Reclaiming Your Power Over Food = Reclaiming Your Authentic Power. An
inset box in the articles text, illustrated with a large strawberry, pursues this
theme, stating that each time you are faced with a choice and choose health, you
are reclaiming your authentic power (Latela, 2005). The construction of this
authentic power as reclaimed holds in place the construction of surgery not as
a drastic violation of the natural body, but as helping the body to be itself
through the acquisition of new skills and capacities. This offers a powerful
rebuttal to the suggestion that WLS is a form of weight loss cheating. As the
participants reiterated constantly: Its not an easy option. No way is this an easy
option. [. . .] Some people even gain weight. And not everybody can cope with
it (Jennifer). However, this is a discursive strategy that also carries signicant
risks, since this also places responsibility for the failure to lose sufcient weight,
or the regaining of weight, clearly onto the individual themselves and away from
the surgery (see also Salant and Santry, 2006). It can be speculated that it is this
discourse of individual, rather than technological, failure that leads many of those
who begin to gain weight to withdraw from the discussion forums.
The ability and willingness to accept the work of dieting like a normal person
is a central element to gaining access to surgery itself, with prospective surgical
candidates required to demonstrate their commitment to doctors prior to
surgery. For example, a study of gastric bypass patients by Juliet Glinski et al.
showed that if there was concern about a patients commitment to make changes
in her diet/lifestyle, surgery would be postponed until she tried the liquid and
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puree diet (keeping a food diary), came to the support group weekly, and started
walking three times a week (2001: 582). Those identifying as candidates for
surgery are also required to demonstrate an understanding and acceptance of the
ongoing nature of this body work. For example, in a case conference published
in the Journal of the American Medical Association (JAMA), Richard Atkinson
(2000) discusses the case of Ms C, a 33-year old woman with morbid obesity.
After a discussion of Ms Cs perceptions of her condition and an evaluation of
the options open to her, he concludes that surgery may be a possibility, as is drug
therapy, although he remains concerned that she has unrealistic expectations for
medical weight loss. He congratulates her for her excellent comprehension of
the need for change of lifestyle, eating habits, and increased activity (2000: 3241),
but remains worried about her anticipation of the time when she will nish
treatment (2000: 3241). Treatment for chronic diseases, he argues, is never
nished and must continue lifelong (2000: 3241).
This can be understood as an example of the indenite discipline that Foucault
identies as the ideal point of penalty today (1977: 227): an interrogation
without end, an investigation that would be extended without limit to a meticu-
lous and ever-more analytical observation, a judgement that would at the same
time be the constitution of a le that was never closed (1977: 227). Paradoxically,
therefore, claims to the authentic new me are predicated on the acknowledge-
ment of the self as an ongoing project that is never nished. As Cressida Heyes
argues in relation to being a Weight Watcher:
One must be a person who will always need to pay attention to weight a once-fat person
who has confessed her past sins decided to reform, but who can never forget that her new, slim
persona is a construction that may slip at any moment. (2006: 134)
You Didnt Have One of Those Silly Stomach Stapling Operations, Did You?
The concept of the new me as always at risk of slipping has two dimensions to
it in the context of WLS. First, it refers to the risk of regaining weight, whereby
the identity of the disciplined subject becomes difcult to sustain; but, second,
either before or after weight loss has occurred, it could also be used to describe
the risk of the surgery itself becoming visible to others. While the desire to be
normal, to eat what everyone else eats and to diet like a normal person are
clear goals among the people I have spoken to, even where a relatively unremark-
able body size has been reached, the production and maintenance of a socially and
culturally intelligible, and acceptable new me is extremely difcult to sustain,
since the fact of having undergone surgery potentially exposes individuals to the
critical evaluation of others for cheating, or simply for having become fat in
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the rst place. For this reason, many of the participants were very careful to limit
who knew about their surgery and consequently had to carefully manage the
ways in which the effects and practices of surgery could inadvertently and un-
predictably render it visible to others.
Most obviously, when WLS is successful, it can produce a dramatic visible
transformation which invites comment from others, especially given the extent
to which the discussion of body size, diet and pounds lost and gained constitute
a key form of discursive currency, particularly among women. Sally, for example,
bumped into a friend on a bus whom she hadnt seen since she had had surgery.
Sally was initially unrecognizable to her friend a very literal rendering of the
new me but when she realized it was Sally, she gasped My god, youve
shrunk!, followed by the accusatory question: You didnt have one of those silly
stomach stapling operations, did you? Sally dodged the question with a strategic
half truth and got off the bus, explaining: I didnt want to get into that rst thing
in the morning. Its not exactly small talk. However, it is not only the trans-
formed body that risks making the surgery visible, but also its practices.
First, those undergoing WLS can usually only eat very small portions of food;
indeed, this is one of the key skills that they have to learn post-surgery. However,
this can bring them to the attention of others, and one of the key strategies that
people used to explain this was simply to claim that they were dieting:
And I can explain to anyone about the portions being much smaller, and I literally laugh it off
by saying Im trying to lose weight. Hello?! [pointing to her stomach]. People will accept that
and they dont say anything. And they dont notice. (Fiona)
The surgically induced inability to eat becomes a parody of dieting like a normal
person an act of passing which is achieved through the mobilization of the
normatively feminine practice of dieting. Particularly among women, there is
nothing unusual about this, especially when the individual may already have a
history of following restrictive eating plans. Several of the participants are also
active members of commercial slimming groups; a move which not only provides
a socially intelligible cover story for the small portions and for the subsequent
weight loss, but also gives them access to the panoptic culture of public weigh-
ins and the meticulous recording of consumption which those organizations offer
(Heyes, 2006: 134; Stinson, 2001). This facilitates the work of dieting like a
normal person and provides a socially supportive context for that work.
There is a second issue associated with the day-to-day work of living with
WLS that makes it visible in ways which are much more likely to invite the
negative evaluation of others than altered eating habits, and which requires careful
management: being sick.
4
One of the key mechanisms through which WLS
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works is the physical restriction of what the body can consume. When the
reduced stomach is full, or the surgically narrowed entrance to the stomach
becomes blocked, the chewed food will be unable to pass into or through the
stomach; the only way this can be relieved is through vomiting the undigested
food back up. This may happen spontaneously, and often with some urgency.
Alternatively, people may seek relief from the discomfort by making themselves
sick, perhaps by drinking water quickly, or by using their ngers. Signicantly,
although several of the participants in my study vomited regularly, it is not some-
thing that is necessarily viewed as intolerable by the participants themselves, not
least because the food itself is chewed but undigested:
. . . because theres no bile, there hasnt been time for bile to form, its the most civilized sick.
You come back [from being sick] and you can . . . youre talking, youre . . . you can possibly
think about eating a tiny, tiny bit, or drink, but you can carry on a conversation and not have
that . . . that acid bile. So it is quite civilized in that respect. (Fiona)
The distinction between civilized sick and other more familiar experiences of
vomiting is drawn by many of the participants in the study (although not usually
in such eloquent detail), and serves to distinguish this civilized vomiting from
that associated with physical illness, for example, or eating disorders.
5
Further-
more, for both those undergoing surgery and their doctors, vomiting is not treated
as indicative of bodily dysfunction, but rather as evidence that the surgery is
working as it should. American surgeon Norman Ackerman, for example, states
this explicitly, arguing: I dont consider vomiting a complication; I call it a side
effect of the operation (1999: 161), and commentator Ellen Ruppell Shell describes
it as an expected and important side effect (2003: 9). The online discussion
forums reect this, with more experienced members repeatedly elding worried
questions from people who nd themselves able to eat a normally sized portion
of food without being sick. However, while being sick is normalized within the
WLS community, it still risks exposing the fact of surgery and, among those who
are aware of the surgery, of undermining claims that surgically altering the body
is a fundamentally normal means of managing weight. Judiths husband, for
example, following a period of problems with vomiting, denounced her surgery
as unnatural; and, similarly, Jennifer described her husband as asking angrily
What have you done to yourself? when, following a dinner in hotel garden, she
had to go in the bushes to be sick.
This points to a whole new set of disciplinary techniques that those undergoing
WLS need to acquire that are very distinct from those associated with normal
eating and dieting; techniques which are communicated through patient-advice
literature and on the website discussion forums between experienced individuals
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and newbies. These include strategies relating specically to managing being
sick for example, carrying a supply of nappy sacks or airplane sick bags for
emergencies, or having a ready repertoire of plausible explanations for suddenly
having to rush to the toilet in a restaurant. These strategies are shared in
discussion forums and support group meetings as a form of expert knowledge.
These coping strategies also exist alongside sets of rules, differing between surgical
procedures, regarding both what and how to eat: what US surgeon Randall Baker
describes as the pouch tools (Janeway et al., 2005: 47). Judith, for example,
blamed her own problems with regular vomiting very explicitly in terms of her
failure to follow these rules:
. . . if I obeyed the rules and stopped eating too quickly and chewed my food more than I do,
things would be easier, but when youve spent a lifetime gobbling your food down, it takes a
long, long time to retrain yourself.
After each episode of vomiting, those who have undergone surgery are urged to
review what and how much they ate as part of the ongoing disciplining of the
post-WLS self; discussion forum members frequently encourage each other,
particularly after a period of deviating from the rules, or when weight loss stalls,
to return to eating soft food in order to review and relearn how to eat with a
surgically modied stomach. In Foucauldian terms, this is an example of discipline
as essentially corrective rather than punitive (Foucault, 1977: 179); the penalty
for transgressing the rules is exercise intensied, multiplied forms of training,
several times repeated (1977: 179), rendering the body simultaneously more
useful, more powerful and more docile (Sawicki, 1991: 83). It is also clear that
both following the rules (by eating small amounts) and not following the rules
(causing vomiting) risk exposing the fact of surgery to others, threatening to
undermine the normality of the post-surgical new me and requiring constant
self-surveillance and management in order to keep the identity of the disciplined
subject intact.
Conclusion
This article has explored some of the ways in which the participants in my study
engaged in the production of the post-WLS re-born new me, which has been,
or is being, rescued from obesity and restored to a more authentic, socially legit-
imized, disciplined self. I have argued that, rather than signifying the relinquishing
of control over the body, WLS is congured by the participants in this study as
enabling them to participate in the normatively prescribed work of disciplining
the body. In many ways, this positions the participants as the supreme objects of
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the war on obesity. However, I have suggested that this also enables them to
locate themselves as its subjects, and it is this, rather than the bodily transform-
ation itself, that is signied by the rhetoric of re-birth and which characterizes
the new (real) me in accounts of WLS.
The participants in my study repeatedly emphasized the role of WLS as a
tool and not a magic pill. This is evidenced in the accounts by the fact that
WLS requires not only the skills and capacities to eat/diet like a normal person,
but also demands new techniques of bodily discipline relating specically to
surgery, such as how and what to eat, how to manage the unpredictable visibility
of the surgery and, nally, how to negotiate the less socially acceptable side
effects of the surgery. It is these skills that dene the re-born new me, and which
can be mobilized to normalize the surgical intervention and rebut accusations of
having cheated. This gives the participants access to a positive identity claim
that runs counter to the persistent denigration that those who are very over-
weight are routinely exposed to. Furthermore, the communal declaration of
happy re-birthday signals a new form of belonging (to the WLS community)
that stands in stark contrast to the exclusion and denigration that many of those
who are visibly large experience routinely.
However, the post-surgical new me of WLS is always a tentative and contin-
gent identity claim which is replete not only with possibility, but also risk. By
minimizing the role of surgery, and by emphasizing their status as disciplined
subjects actively engaged in the work of weight management, the participants
held in place the dominant discourses of the war on obesity as a matter of
individual responsibility (see Gard and Wright, 2005) and, consequently, risk the
transfer of blame for any subsequent weight gain onto themselves, rather than
the surgery (or the surgeons). Furthermore, the process of working, through
surgery, towards a weight that is deemed medically healthy can expose indi-
viduals to health risks. This is a contradictory outcome that calls into question
the dominant treatment of slimness as a proxy for health. Consequently, the
disciplinary techniques of WLS, like those of the diet industry more generally
(Heyes, 2006), can be seen as simultaneously enabling and constraining in ways
that are potentially (but not always) problematic for individuals, even when the
surgery is successful in terms of weight loss. The happy re-birthday of those
undergoing WLS, therefore, is never a straightforward or easy option, either in
terms of material practice or in relation to the management and negotiation of
the discursive resources through which that surgery is made meaningful.
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Happy Re-birthday: Weight Loss Surgery and the New Me I 131
Notes
1. There is not space within this article to detail the different surgeries, but these are discussed in
a number of patient advice and medical texts (Ackerman, 1999; Buchwald et al., 2004; Flancbaum,
2003; Janeway et al., 2005; Kurian et al., 2005).
2. Even for those who meet the NICE criteria for NHS-funded treatment (a BMI of >40kg/m
2
, or
>35kg/m
2
where co-morbidities are present), individual Primary Care Trusts (PCTs) are not obligated
to provide funding, with some setting much higher qualifying BMI thresholds in order to limit the
number of potential candidates, and others refusing to provide any funded weight loss surgery.
3. I am very grateful to the Collaboratory: Social Anthropology and the Life Sciences (C:SL) at
Humboldt University, and to the Suntory and Toyota International Centres for Economics and
Related Disciplines (STICERD) at the London School of Economics, who provided grants to support
the interview phase of this project.
4. Other problems which potentially contravene social norms include (with some surgeries) foul-
smelling wind, and there is a side effect associated with gastric bypass surgery called dumping, where
the small bowel lls too quickly with undigested food from the stomach, causing diarrhoea and other
debilitating symptoms including weakness, dizziness, sweating and abdominal cramps (e.g. Ackerman,
1999; Janeway et al., 2005). There is no space to discuss these here, but they equally involve careful
management in order to preserve the construction of the post-surgical body as normal.
5. A very small number of participants did display disordered eating habits in relation to being sick.
For example, as Jessica described:
I can still use food in a way, like strawberries and cream if I really need to, I can still use
food as a comfort, knowing that its going to come back up, that its going to taste just as nice,
and Im going to have that x. And I have done that probably two, maybe three times in the
last three months. (see also Saunders, 2004: 100)
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Karen Throsby is a lecturer in Sociology at the University of Warwick. Her research interests focus
on issues of gender, technology and the body and she is the author of When IVF Fails: Feminism,
Infertility and the Negotiation of Normality, published by Palgrave in 2004. She is now researching
and writing on the medical management of obesity.
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