Fostering Intersectional Body Image

For this article, I am intentionally using the word fat when talking about clients to reclaim it as a neutral body descriptor and help you sit with your own feelings about it rather than using overweight or obese (Kinavey & Cool, 2019). However, with research that uses overweight and obese, I will utilize the authors’ language.

Fears of fat cannot be separated from experiences of racism, classism, and sexism in reinforcing structural inequities (Crenshaw, 1989; Hill-Collins & Bilge, 2020). As Strings (2019) discusses, anti-Blackness and anti-fatness are intertwined due to placing thin White bodies as the ideal “pure” body compared to fat Black bodies and having the thin body as the ideal to strive for. In particular, fat gender diverse people of color grapple with being misgendered or discriminated against due to how race, ethnicity, fatness, and gender presentation impact others’ perceptions of them and their gender identity (Luna, 2021).

With the rise of anti-trans sentiment, there has been an uptick in research defining gender dysphoria as a social contagion that specifically targets cisgender White teen girls to try and prevent them from losing the ability to have children later in life (Schrier, 2020; Jo Hsu, 2022). With this increase in anti-trans rhetoric, trans people have experienced discrimination from doctors and therapists and have limited access to care (Teti et al., 2021). For fat trans people, their body mass index can prevent them from getting gender-affirming surgeries even with limited to no scientific backing regarding risks after surgery (Brownstone et al., 2021).

With laws and regulations about how bodies present in the world, particularly bans surrounding gender affirming care, research on race, intersectionality, and trauma, we as marriage and family therapists (MFTs) and medical family therapists (MedFTs) must understand how to provide quality care to our fat and gender-expansive clients of color. This article will first discuss what weight stigma is and the impact on clients’ biopsychosocial health. For an analysis on anti-fatness through Bronfenbrenner’s ecological systems model, I encourage you to read Sullivan et al.’s article (2024). This current article is also a call for therapists to help foster positive body image in their clients while naming the impacts of systematic racism, fatphobia, and transphobia to help clients and their families foster both resilience and resistance to negative messaging.

Weight stigma and biopsychosocial health

Weight stigma is generally defined as the prejudice, discrimination and stigma associated with fatness. This can show up as assuming negative qualities with someone’s larger body such as fatness with laziness, or through public places only having chairs that fit thin people (Panza et al., 2020). Globally, 56-61% of individuals experience some form of weight stigma in their lifetime from family members and healthcare providers, which include doctors, therapists, counselors and psychiatrists (Puhl et al., 2021). Weight stigma is also connected to increased risk for earlier death and various adverse physical and mental health experiences such as increased blood pressure, suicidality, and unhealthy weight control behaviors (Brochu, 2020; Keast et al., 2023; Lee et al., 2021; Sutin et al., 2015).

Weight stigma also negatively impacts people’s relational health. In families, this can show up as passive aggressive comments about weight, unsolicited dieting advice, exclusion, or weight teasing (Lawrence et al., 2022). These messages reinforce participants’ negative beliefs about themselves and their bodies throughout their life. Weight stigma in romantic relationships can show up as weight criticism (i.e. “you should lose weight”), negative self-beliefs due to fat (i.e. “I’m unattractive and don’t deserve romantic relationships”), anti-fat attitudes, or unequal treatment in their relationship due to fatness (Lawrence et al., 2022). When partners experienced weight stigma, they were less likely to be satisfied in their relationship and were more likely to have conflict with each other (Schmidt et al., 2023).

Our beliefs about fat bodies and how our bodies may have been shamed in the past impact how we show up and provide therapy for people across body size. In a survey of MFT learners, those who were masters-level clinicians, those who identified as women, and those who self-identified as overweight or obese were more likely to endorse explicit bias regarding overweight/obese clients (Pratt et al., 2015). When working with clients on weight-loss, MFTs utilized either CBT or other post-modern theories when working with clients yet primarily developed care plans from the therapist’s own perspective without a collaborative and client-centered approach (Pratt et al., 2014).

Clients discuss that microaggressions about their weight negatively impact their therapy experience. Some mentioned their therapists either fixating on their weight as the problem regardless of why they came to therapy while others discussed feeling ignored when participating in group therapy (Akoury et al., 2019). Clients also reported non-accommodating office furniture (an invisible access need; Kinavey & Cool, 2019). These experiences demonstrate how fat bodies become both invisible and hyper-visible in the therapy room.

Calls for therapists to cultivate positive body image for fat TGNB clients of color

A component of cultivating positive body image in fat gender-diverse people of color is the ability to access gender-affirming care (Bolle, 2025). There are benefits in helping trans, nonbinary, and gender diverse clients receive gender-affirming care. For adolescents and young adults, having access to hormone replacement therapy decreases suicidal ideation and depressive symptoms while increasing well-being (Green et al., 2022; Nath et al., 2024). However, with legislation across the country that have banned or are attempting to ban gender-affirming care for people across the lifespan, it is important to know how we can advocate for clients in and outside of the therapy room.

There are guidelines explaining how to work with gender diverse clients across the lifespan while considering our current sociopolitical climate and how other intersections of identity such as spirituality and neurodivergence impact care (Carrington et al., 2025). When working with fat, gender-diverse clients of color on body image, two therapy approaches that can be utilized to increase positive body image and disrupt the intersections of fatphobia, transphobia, and racism are emotionally focused therapy (EFT) and socio-emotional relationship therapy (SERT).

EFT helps to foster bonds between partners and family members by challenging negative interaction cycles and helping people connect to their primary emotional experiences and be able to express them in their close relationships (Johnson, 2019). With EFT, therapists should be aware of how larger systems of oppression like racism, fatphobia, and transphobia shape people’s attachment styles. Tracking the negative cycle between partners or family members can be useful in identifying what leads to the use of weight criticism/teasing (Johnson, 2019). Enactments should be used to help facilitate conversations about underlying attachment yearnings and how this links to negative body image (Smith et al., 2022). The attachment injury repair model can be utilized to facilitate repair between partners and/or family members when there have been ruptures due to weight criticism and teasing (Johnson, 2019).

SERT also can be utilized in helping clients cultivate positive body image. SERT is intentional about exploring how identity and power shape clients’ emotional experiences. This is done through asking questions that link emotions to larger discourses (i.e., men must be strong/cannot be vulnerable), help clients imagine alternate ways of being with others and the world, and help people relate from a place of equity (Knudson-Martin, 2024). We as clinicians can name and explore with clients how larger social discourses shape body ideals and their feelings about their body.

Some questions informed by SERT that can be used as self-of-the-therapist questions and in your work with clients are as follows (Knudson-Martin, 2024):

• What are the societal messages about people with bodies like yours?
• How do you think racism, cissexism, and fatphobia impact your relationship to your body?
• How does your relationship with your body shape your relationship with other people?
• How do you want to imagine your relationship with your body differently?
• What would relating to your body in a more positive way look like?

I want to name that it can be easy to be overwhelmed and hopeless given the uncertainty of the current sociopolitical climate. However, I want to name the importance of joy in clinical work since it invites clients to notice aspects of their lives that they find meaningful and helps them imagine alternate futures that are more equitable and filled with hope (Knudson-Martin, 2024; Westbrook & Shuster, 2023).

There is precedence for us to be proactive in naming injustice and advocating for change on a larger scale (American Association for Marriage and Family Therapy, 2015). As Audre Lorde articulates, our fear and our silence will not save us (1977). AAMFT released a position statement regarding the provision of gender-affirming care, imploring us to practice within our scope and/or referring clients to clinicians who have training in providing gender-affirming care (2024). However, this does not mean you should not receive training yourself in providing gender-affirming psychotherapy; I invite this as an opportunity to listen and pay trans and nonbinary therapists of color for their knowledge and education on providing affirming care. I also encourage you to use your voice in your community through education, support groups, and understanding city-wide and statewide legislation that impacts our clients, and join alongside others in writing policy briefs or speaking on behalf of clients during legislative sessions. Even if it feels intimidating, we have the knowledge and skills to make change on a larger scale for the betterment of our clients and communities.

Conclusion

MFTs and MedFTs need to have an intersectional approach when providing care for clients across identity constellations to ensure that we are keeping in mind how larger systems of power inherently shape clients’ body image. In an interpretative phenomenological study on how fat gender diverse people of color cultivate positive body image, participants discussed the importance of providers utilizing an intersectional lens while being cognizant and critical of how white supremacy, racism, and cissexism inform body ideals (Bolle, 2025). Participants also expressed how being present with them as a whole client versus viewing them through the lens of pathology/diagnoses helps to foster and maintain a positive body image (Bolle, 2025). Participants also discussed how challenging white supremacy, transphobia, and fatphobia in themselves allowed them to create their own body ideals and encouraged closeness with others (Bolle, 2025). Ultimately, helping clients cultivate positive body image and tap into joy is both an individual and communal act of resistance against messaging that tries to erase and deny the existence of fat, gender diverse people (Westbrook & Shuster, 2023).

>> Download AAMFT’s Gender-Affirming Care: Guidelines for Working Systemically with Transgender, Nonbinary, and Gender Expansive Clients

Key takeaways

• Balance being a collaborator, advocate, and constant learner alongside trans clients, fat clients, and clients of color when helping them, their partners, and their families navigate various systems (i.e., school, work, legal, and medical systems; Boe et al., 2020).
• Use intersectionality as a lens when understanding clients’ presenting concerns about body image (Cooke & Few-Demo, 2021).
• Simultaneously hold space for the difficulty of navigating the current context and explore the joys of being BIPOC, fat, transgender, nonbinary, and gender diverse (Westbrook & Shuster, 2023).
• Be critical of how your own ideals of health/wellness and body ideals show up when working with clients across the body size spectrum.
• Listen to fat, transgender and nonbinary clinicians of color and financially compensate them for their time and education.