The decision of an obese woman to have bariatric surgery: the social phenomenology^*

La decisión de la mujer obesa por la cirugía bariátrica a la luz de la fenomenología social

Abstracts

Objective

To understand the process by which an obese woman decides to have bariatric surgery.

Method

A qualitative survey with a social phenomenology approach, carried out in 2012, with 12 women, using the phenomenological interview.

Results

A woman bases the decision to have the surgery on: the inappropriateness of her eating habits; a physical appearance that is incompatible with an appearance that is standardized by society; the social prejudice that she has to live with; the limitations imposed by obesity; and her lack of success with previous attempts to lose weight. Outcomes that she hopes for from the decision to have the surgery include: restoring her health; achieving social inclusion; and entering the labor market.

Conclusion

This study allows one to reflect that prescriptive actions do not give a satisfactory response to a complexity of the subjective questions involved in the decision to have surgery for obesity. For this, what is called for is a program of work based on an interdisciplinary approach, and training that gives value to the bio-psycho-social aspects involved in a decision in favor of surgical treatment.

Obesity; Bariatric surgery; Women’s health; Qualitative research

Objetivo

Comprender el proceso de toma de decisión de la mujer obesa por la cirugía bariátrica.

Método

Investigación cualitativa con abordaje de la fenomenología social llevada a cabo en 2012, con 12 mujeres, utilizándose la entrevista fenomenológica.

Resultados

La mujer funda su decisión por la cirugía en la inadecuación de sus hábitos alimentarios, la apariencia física incompatible con la estandarizada por la sociedad, el prejuicio social vivido, las limitaciones impuestas por la obesidad y el fracaso de los intentos previos de adelgazamiento. Ante la decisión por la cirugía tiene como expectaciones rescatar su salud, incluirse socialmente e insertarse en el mercado laboral.

Conclusión

El estudio permite reflexionar que las acciones prescriptivas no responden a la complejidad de las cuestiones subjetivas involucradas en la toma de decisión por la cirugía de la obesidad. A tal efecto, requiere un trabajo pautado en la interdisciplinaridad y una formación que valorice los aspectos biopsicosociales involucrados en la decisión por el tratamiento quirúrgico.

Obesidad; Cirugía bariátrica; Salud de la mujer; Investigación cualitativa

Objetivo

Compreender o processo de tomada de decisão da mulher obesa pela cirurgia bariátrica.

Método

Pesquisa qualitativa com abordagem da fenomenologia social realizada em 2012, com 12 mulheres, utilizando-se a entrevista fenomenológica.

Resultados

A mulher fundamenta a decisão pela cirurgia na inadequação dos seus hábitos alimentares, na aparência física incompatível com a padronizada pela sociedade, no preconceito social vivenciado, nas limitações impostas pela obesidade e no insucesso das tentativas prévias de emagrecimento. Diante da decisão pela cirurgia tem como expectativas resgatar sua saúde, incluir-se socialmente e inserir-se no mercado de trabalho.

Conclusão

O estudo permite refletir que as ações prescritivas não respondem à complexidade das questões subjetivas envolvidas na tomada de decisão pela cirurgia da obesidade. Para tanto, exige um trabalho pautado na interdisciplinaridade e uma formação que valorize os aspectos biopsicossociais envolvidos na decisão pelo tratamento cirúrgico.



Obesidade; Cirurgia bariátrica; Saúde da mulher; Pesquisa qualitativa

Introduction

The global epidemic of obesity, as it is known in the contemporary world, reflects the social, economic and cultural problems currently faced by developing or more recently industrialized countries, and also by ethnic minorities in disadvantaged situations in the developed countries(¹). This is an illness with a complex and multifactorial etiology, resulting from an interaction of genes, environment, lifestyle and emotional factors that can lead individuals to serious social and psychological consequences, with amplified damage to life(²).

The World Health Statistics Report for 2012, prepared by the World Health Organization (WHO) indicated that between 1980 and 2008 obesity doubled in all the regions of the world. This means half a billion people – 12% of the world’s population – are considered to be obese(³).

The survey carried out by the Brazilian Geography and Statistics Institute (IBGE) in 2008-9 indicates that the Brazilian rate of obesity is 12.4% in men, and 16.9% in women(⁴). A greater prevalence of obesity in the female gender is also seen internationally(⁵).

Bariatric surgery, also known as gastroplasty or weight loss surgery, has been disseminated as a possible option for control of the condition. As an option for treatment of obesity, it makes possible an improvement in quality of life, and a reduction in the worldwide death in this population which may be more than 200% when compared with eutrophic individuals(⁶).

It is found that the percentage difference in prevalence of obesity between the sexes is small if compared to the significant difference in demand for bariatric surgery between men and women. Surveys carried out both in Brazil and internationally have shown that of all the obese persons in the pre-operative stage of bariatric surgery, approximately 80% were female(⁷-⁸).

A study carried out on candidates for gastroplasty showed that, although the surgery was considered the most effective means for control of weight in the longterm, the decision is not a simple one, because it takes place surrounded by fear in relation to the risk of surgery, and also the pain and the complications that could arise at the post-operative stage. Add to this, further, the pressure of the family on the obese person, which can create a feeling of inadequacy that generates self-demand, anguish and anxiety(⁹). Such corporal regulation is more exacerbated in relation to the body of a woman, who sees herself as coerced by society to fit into a given stereotype of beauty related to the thin body(¹⁰).

Faced with the complexity inherent to this context, it is seen that nursing has taken a timid approach on the subject of obesity as it interfaces with bariatric surgery. An inspection of recent publications in Qualis Aperiodicals on nursing shows that the scientific output in this area includes studies on assistance by nurses in the pre-, trans- and post-operative phases of bariatric surgery(¹¹-¹³), quality of life(¹⁴) and the demographic and clinical profile of the patients that are candidates for gastroplasty(¹). Internationally, there have been qualitative studies that describe the experience of subjects in the pre-operative phase of bariatric surgery(⁹-¹⁵), but these have not been published in nursing periodicals.

In view of the above, the following issues of concern arise: what leads an obese woman to decide for bariatric surgery? What factors are involved in the woman’s process of facing up to that decision? What are her expectations?

This study aimed to understand the process of taking of the decision by an obese woman in favor of bariatric surgery. By investigating and revealing the experience of a group of obese women who decided in favor of gastroplasty, this investigation makes contributions that help expand the international scope of scientific output on nursing, since this phenomenon has been little explored in this area of knowledge.

Method

A qualitative-approach survey grounded on the Social Phenomenology of Alfred Schütz, who places the social relationship as the fundamental element in the interpretation of the meanings of people’s actions in the day-to-day world, also referred to as the world of life or the social world(¹⁶). This world constitutes the central conducting channel of the analysis of a woman’s decision to have bariatric surgery, as carried out in this investigation.

The scenario and context of the study is the Hypertension, Diabetes and Obesity Control Service (Serviço de Controle da Hipertensão, Diabetes e Obesidade, SCHDO), which is part of the public health network of a municipality in the Zona da Mata region of the region of the Brazilian state of Minas Gerais. This service isqualified by the Unified Health System of the municipality studied, as a referencefor serving obese people in the pre- and post-operative phases of bariatric surgery. It has a multi-professional team that works on an interdisciplinary logic providing individual and group assistance, weekly, to this clientele.

The invitation to participate in the survey was made after the group activities. At this time the women were informed about the objectives of the study, and about the doubts in relation to their participation. Those that accepted inclusion in the survey signed the Informed Consent Form.

The method of phenomenological interview was used to obtain their testimonies, since that method comprises open questions that enable a person to remain accessible to intentional acts by the other, allowing the flow of consciousness of the participant to be presented to the investigator(¹⁶).

Over the period October through December 2012, interview were held with thirteen women who were awaiting gastroplasty in the queue of the SCHDO, and attended the educative groups offered by that service. The time that they had been registered with the SCHDO was not taken into account, since what was important was the fact that they had decided in favor of bariatric surgery.

The testimony of one of the interviewees was excluded, because at the time of obtaining of the data she showed insecurity as to the decision in favor of gastroplasty, and this reduced the total of participants to 12. The following questions targeted the interview: how was it for you, deciding in favor of bariatric surgery? What are your expectations?

The majority of the participants had been obese since infancy, and had decided in favor of bariatric surgery a minimum of eight months and a maximum of five years earlier. Most of them were married, with children, had not completed secondary education, and were aged between 29 and 60. The number of participants was not pre-established, and the interviews ended when the objective of the study had been reached and concerns responded to. To ensure anonymity, interviewees were identified by the letter “E” and an Arabic numeral, recording the order in which the interviews were held (E1 to E12).

The organization and analysis of the results were grounded on studies arising from researchers of the Social Phenomenology of Alfred Schütz(¹⁷-¹⁸). For this purpose, a painstaking reading was made of each testimonial, in full, and the significant content extracted from the material was grouped, in an attempt to create concrete categories of experience undergone – an objective synthesis of the different meanings of the action defined as decision to have bariatric surgery, in the form that it emerged from the life experience of the participants. The discussion of the categories was based on the schematic and theoretical-methodological references adopted. This study was submitted to consideration by the Ethics Research Committee of the School of Nursing of Sao Paulo University, with Opinion given in favor, No. 73.616/2012.

Results

The taking of a decision in favor of bariatric surgery is an action that has its origin in the daily life of the obese woman and is related to the group of experiences that she lives through. In this context, it brings in personal and social aspects that indicate her process of decision, expressed in the category Decision to undergo bariatric surgery.

When reflecting on the taking of the decision in favor of gastroplasty, the woman emphasizes that her daily life is permeated with inappropriate eating habits that culminate in the process of construction of an obese body:

(…) in my house, there’s pork crackling, pork meat, mayonnaise at the weekend, salpicão sausages, cake, and there’s everything that there really shouldn’t be. (E6)

Since she consumes calorific foods, and in great quantity, as a result the woman has the appearance associated with a body of excess weight, which is far from the socially established standards of beauty. This constitutes a contravention of the norm, and develops into a motivating factor for the decision to change her body through surgery.

I can’t go to the swimming pool, because I’m ashamed of my body. Sometimes, when I join a group of friends, I’m the only fat female. And then I am really very ashamed of myself. That’s my main worry.(E4)

As well as her physical appearance, a woman also takes her health situation into account in her decision process, since that too has been altered by her obesity. The physical limitations arising from the comorbidities that accompany obesity lead the woman to seek to lose weight through bariatric surgery, and she puts aside and/or minimizes potential risks to her health: –

My organs are all overburdened.There is even risk of my no longer being able to walk because of the problem of cartilage in the knee.So I got up my courage and am very excited about doing the surgery.(E5)

The limitations of a physical nature reflect very strongly in the social dimension, making it possible to carry out daily activities – and this leads to consideration of the surgery:

At home, you can’t manage to do anything, in the street, you can’t manage to walk.I walk with great difficulty (…) there’s no other way other than the bariatric surgery.My life is leading me to make this move.(E9)

In this context, questions of a social order are highlighted, especially those that place a woman as a person who, as well as being limited, is not accepted, assuming a position of marginalization when faced with the body-standard established in the contemporary world, which results in social isolation:

I’m prejudiced, indeed, against myself.I don’t like to ride on the buses, because other people talk, look, laugh.I don’t pass in front of the school at a time when school is coming out, because I know children will get up to things, and make fun of me. (E8)

The others laugh in my face, call me fat, ugly.And then I get very sad.So I began to separate myself from work, I gave up college, I gave up everything.(E11)

The experiences that a woman undergoes with an obese body lead her to seek to lose weight.However, her attempts to lose weight and to maintain weight are marked, over the length of her life, by failed experiences, and she sees in gastroplasty the final option for the desired loss of weight:

I have already dieted a lot, and none of it was any good.I got thinner, and then I got fatter all over again.It doesn’t work, I have to do the surgery (…).(E10)

The decision in favor of bariatric surgery involves facing the fear that arises from the risk of the surgery, which the woman overcomes based on the consequences that obesity brings to her life:

I said that I didn’t want it because I’m afraid, I’ve seen cases that went wrong. And that fear remained (….) because of having, in the past, having seen a lot of people dying in surgery (…) and I didn’t used to want the surgery, but now I want it. (E7)

When she considers the motivating factors for the process of taking a decision in favor of bariatric surgery the woman expresses projects related to the desired loss of weight, which we grouped in the category Expectations for life after bariatric surgery
.

The woman wishes to be free of the limits imposed by obesity, seeing, ahead, a life without pain, with the capacity to exercise regularly, achieving a better quality of life:

I want to have health and quality of life.(E1)

(…) I believe that after I do the surgery I will have a much better life.The limitations that I have now I will have no more.(E3)

Associated with this, the decision for bariatric surgery is seen by the woman as a possibility of having a body that would permit her to feel included in the environments that she frequents, or which, on account of her obesity, she does not allow herself to frequent:

I want to have a beautiful body, to be nice and thin, I want to walk, go around without having other people looking at me.I want to be able to sit down anywhere, be well received.(…) my greatest dream is to put on my swimming costume, go to the beach and move around wherever I want.(E7)

In the context of the family, this inclusion is also aimed for, expressed by the desire to take part in leisure activities with the children:

(…) I want to be able to take part more in the infancy of my children, of leisure

(…) not only to be watching, but to participate.(E4)

The woman, as from the decisions in favor of bariatric surgery, sees herself as being in a condition to recover her self-esteem, resuming an active and productive life:

(…) I want to get a job again and pay for a gym for me to exercise.(E6)

(…) fat people can’t get a job, they can’t succeed at anything. I want to work again, to study.(E11)

Discussion

The stereotype of feminine beauty is attributed to a pattern that is given by the social reality, which needs to be considered in this study. The identity of woman in the western world is anchored on the standard of the thin body, and this characteristic of identity has been laid down over time in her social world.

The Social Phenomenology of Alfred Schütz grounds the discussion on the social structure, and highlights the relationship between human beings as a fundamental element in the interpretation of meanings. It emphasizes comprehension of the social phenomena described in the world of life, also referred to as the social world or the day-to-day world(¹⁶). The latter is permeated by a structure that promotes the subjects’ social construction and influences their relationships with themselves and with other people.

To live in the ‘world of life’, man orients himself by the way that he defines the scenario of action, which he interprets based on his existential motives.The motives that relate to the project are called reasons to and those that are based on the repertory of knowledge and on the experience lived through in the bio-psycho-social environment of the subject are referred to as reasons why(¹⁶). The group of reasons to and why give rise to the flow of action(¹⁶).

In this respect, the action of a woman to decide for the surgery is based on inappropriate feeding habits practiced over the length of her life, culminating in the construction of an obese body. The comprehension of the relationship of the subject with food takes place as from birth, and arises from her primary habits, constituted in the universe of the family, especially with the maternal figure, and also in the social media in which she lives(¹⁹).

The results of the inadequate eating habits come out in the woman’s physical appearance, and also in her inter-subjective universe, in which she establishes her relationship with the Other. By presenting herself socially with a body that indicates an inappropriate diet, she places herself as a target for prejudice, which has a very strong effect on her social relationships.

The stigmas and prejudices attributed to the physical appearance of an obese person are revealed through looks, insults and forms of aggression, that embarrass the person. In a society that places extreme value on appearance, it is natural that a givenphysical aspect, which fosters discrimination and causes suffering, should be something that motivates the individual to seek a solution. The psychological suffering lived through as a result of prejudice and exclusion, which is present among the obese, damages the mental health of those people, stimulating the interest in bariatric surgery(²⁰).

As well as a physical appearance that does not represent the standard dictated by society, it has been evident in this study that obesity leads the woman to a situation of maladjustment in health, imposing limits that compromise her quality of life. The limitations of a physical and social nature arising from obesity lead the person to incapacitating reactions, which include withdrawal from work, and restrictions on physical activities and leisure, as well as the emotional burden resulting from bodily appearance(²¹).

This burden becomes even more significant when it takes place in the feminine public, at whom society directs an even greater level of demand for achievement of a thin body. Under western culture, being thin contributes to the perception of being a woman. Thus, women see themselves as obliged to experience, constantly, the distance between their real body, to which they are attached as if imprisoned, and the ideal body which they incessantly seek to achieve(²²).

In this present study it was shown that the social demand is strongly linked to the woman’s decision in favor of bariatric surgery, since the questions relating to physical appearance and to the prejudice that is undergone are listed as motivating factors for them to decide in favor of gastroplasty. The phenomenon of obesity appears to signal that the condition of being obese produces an intense effect on the life of a person, and also on her social relationships. That is to say, the diagnosis of obesity, especially of morbid obesity, can lead to suffering and important social impediments(²³).

In addition to the above issues, a woman living with obesity and with the results that it produces in the bio-psycho-social context, seeks to relieve herself of the obese body through various frustrated attempts to lose weight.

The majority of obese people seek to lose weight through conventional treatments such as diets, physical activity and medication. However, when these attempts do not provide a response, they decide in favor of bariatric surgery(²¹,²⁴). When assessing her experience of living with obesity, the woman considers that it is worth running the imminent risk of a surgical procedure, transcending the fear and deciding in favor of the gastroplasty.

This has also been seen in a study carried out in Braga, Portugal, with candidates for bariatric surgery, in which there were reports of the fear related to the surgical risk and the post-operative pain. However, as in the present investigation, the candidates overcame the fear and decided for the surgery, imbued with expectations of improvement of quality of life after the gastroplasty(⁹).

The social world is the scenario in which man interprets his possibilities and faces his challenges, and is related to how he situates himself in the world (his biographical situation). His history, grounded in and gaining its meaning from his prior subjective experiences, constitutes a repertory of knowledge that is available and accessible to him, in accordance with his biographical situation(¹⁶).

Thus, the taking of a decision in favor of bariatric surgery by an obese woman is understood in this study as a process which begins in her prior life, in which her experiences with obesity are laid down. It is also a part of her present moment, in which she sees in the surgery the most promising option for dealing with obesity. Finally, this process is expressed as that woman’s expectation following the decision in favor of the surgery.

Thus, the decision in favor of the surgery refers back to a conduct that is projected by the woman, which is aligned with the social reality in which she lives, especially about her body as circumscribed in this reality. The submission to the surgical act is configured as a possibility of the desired weightloss and of the abandonment of the obese body, which is expressed in the present moment.Schütz considers that the subject, when projecting the action, anticipates the act as if it had been carried out, and the possibilities of carrying it out are directly linked to the elements of the present time.The biographical situation and the inventory of knowledge available and accessible thus conditioned the projection of the action(¹⁶).

The woman’s decision in favor of bariatric surgery is permeated by expectations related to the change of life that she seeks as from the moment of her submission to this procedure. In this context, the principal objective of the surgery is to confer upon the obese person a better condition of health and, consequently, improvement in her quality of life(²³,²⁵).

The bariatric surgery is also seen by the woman as something that makes possible her inclusion in society.The expectation of feeling socially included was also observed in a study carried out in the southern region of Brazil, with people in the pre-operative phase for gastroplasty. The desired changes were related to ceasing to be a source of jokes and prejudice, strengthening participation in both social life, and leisure activities with the family(²⁰). The evidence of that study is in line with the expectations of the participants in this present study.

Another project highlighted by those who gave testimony relates to being able to participate in the job market, since obesity can limit and/or prevent actual doing of a job. This expectation was held by women in a study held in the town of Juiz de Fora, in the state of Minas Gerais, who were able to get jobs after losing weight through surgical treatment(²⁴). Added to the resumption of living in society, joining the job market has a positive effect on the quality of life of the person who has undergone the operation and of those who participate in his or her social circles(²¹).

Thus, bariatric surgery is seen by those who have submitted to it as a path with various possibilities. Starting from the achievement of the desired weight, people see themselves once again socially empowered, getting a job, and recovering their freedom and the independence that had been lost due to obesity(¹⁵).

The decision in favor of bariatric surgery by women taking part in educative groups of an obesity program brings with it a peculiarity that impedes the generalization of the results presented. In this sense, it is suggested that other social groups that experience the process of taking a decision in favor of gastroplasty should be investigated, to further expand comprehension of the phenomenon.

Conclusion

This exercise in comprehension of the process of a woman’s taking of the decision in favor of bariatric surgery indicates important aspects that should be considered by health professionals who provide care to this clientele.These aspects initially are found in the life path of the woman who has an obese body, and become the essential reason for the action of deciding in favor of the surgery.

An approach based on the social phenomenology of Alfred Schütz produces the conclusion that the existential reasons related to the decision in favor of gastroplasty are strongly influenced by issues of a social nature. This is true both of those reasons that are the grounds for the decision – related to a woman’s experience of living with obesity – and also to those reasons that form the basis of her expectations for life after the surgical procedure.

This investigation calls attention to the aspects that transcend the organization of the services and the actions of prevention and treatment designed for obese people, currently seen as priority in care for non-transmissible chronic diseases in the ambit of the SUS.Beyond a structural approach, in the form of a healthcare network directed towardsthis clientele – which is undeniably a pressing need – this study indicates that to deal with obesity it is necessary to reach out to the obese person and understand the cultural and inter-subjective universe in which the process of construction of obesity takes place.

The experience of construction, and the desire for de-construction – through bariatric surgery – of the obese female body indicates to health professionals the importance of paying greater attention to the psychosocial aspects that are interwoven with the woman’s experience of living with obesity. This is to reiterate that prescriptive actions and actions guided by the biomedical model do not satisfy the needs presented by this clientele. In this respect, the aspects that strengthen the maintenance of the obese body should be investigated and worked on from a multi-professional and interdisciplinary point of view both with the people who are in the pre-operative phase and also with those who have already submitted themselves to gastroplasty.

In this context, health professionals can and should propose strategies of individual approach – in consultations, home visits, etc. – and also a collective approach – through educative groups – that works at the same time with the obese person and with the other members of the person’s family, so that there is a commitment to an appropriate food plan, increase of self-esteem, change in her lifestyle, and also demanding co-responsibility on the part of the obese person for the bariatric surgery to be part of a successful experience.

The results also evoke the importance of the subject of obesity in the process of education and qualification in the field of health, indicating the importance of leading future professionals to reflect on this subject beyond the biomedical point of view, giving value to the obese person from the bio-psycho-social point of view. They indicate, finally, the need for increase in qualitative investigations that can approach the innumerable facets of this so complex phenomenon, so that new investigations may be proposed with the aim of elucidating the multiple mechanisms involved in obesity.

• *
  Extracted from the thesis “O processo de tomada de decisão da mulher obesa pela cirurgia bariátrica: uma abordagem compreensiva”, Nursing Faculty, São Paulo University, 2013

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Publication Dates

• Publication in this collection
  Dec 2014

History

• Received
  04 Aug 2014
• Accepted
  14 Oct 2014