Wednesday, 28 February 2018

On failing out loud

As a fat person, I’m very familiar with failure. My body, to most, represents a failure. A failure of discipline. A failure of self control. A failure to appropriately manage my body and the burden it may become for society (NEOLIBERALISM, AM I RIGHT?!)

As a super fat person, I’ve spent decades failing at making myself smaller. Bodies get to be my size after decades of succeeding, and then failing, at weight loss. I get the congratulations and appreciation when I succeed to lose. And the sheltered looks of pity and “you’ll get ‘em next time” pep talks when I fail through growth.

My failures at weight loss are public. People in my daily life know when I’ve failed. I don’t have to tell them, it’s written on my body. Social media makes it more likely that people who entire my life long after those failures could discover them for themselves; here’s a memory for you from 10yrs and 100lbs ago, Cat. Hoozah!

My failures as an academic, though, aren’t as public. No one knows if an article is rejected by an editor, or if I’m turned down for a funding grant, unless I chose to tell them. And while I do speak about such things with my close friends and colleagues, I don’t share them on social media in the same way I share my successes. We don’t talk about failing in academia very often, and this probably leaves many out in the cold. It may appear that everyone else is only ever succeeding, if that’s what we share on social media. So, I’m going to work on failing out loud.

Most recently, I failed to secure an appointment to a faculty position I really wanted. In many ways, it was a dream posting. It’s in an awesome team doing critical health scholarship in the University where I’m already on faculty. My work on fat stigma & oppression would have fit in well with these colleagues, and it would have been a nice change to share a corridor with scholars who work in a complementary field to my own. But they went with someone else, as often (usually?) happens in academia. They decided I wasn’t the best fit for them, and that’s ok. I’m bummed, and disappointed, but not terribly surprised. And I’m taking some comfort in knowing I did my very best in my research presentation and my interview. But it’s a failure, for sure. One that many experience.

I’m not here to write about what you can learn from failure. Or about whether it is better to try and fail then not try at all. I’m vocalising a big failure so others might hear it – see it – hear about it. Maybe it’ll help. Melanie Stefan is credited with the idea of a CV of failures; since her piece in Nature, many successful academics have crafted failure CVs to sit alongside their regular CVs as evidence that all of us have failed along the way. All of us have heard “No” at some point. Many have taken issue with the failure CV, pointing out that most people who produce them do so from a position of privilege.

I’m not planning to create a CV of failures, although I have documented in many places my failures at becoming smaller. But I will make an effort to talk openly about my losses across social media; maybe others would like to join me?



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Tuesday, 27 February 2018

The Shame of my Home Game

This post talks about how anxiety and depression can impact our lives in unexpected and often not talked about ways. If you’d rather not know about the very personal impact of these things on me, or feel it may be triggering for you, please come back to the blog another day or feel free to explore the archives. Thank you and take care of you! <3

********************************

 

Today what is on my mind is my mind, literally. Weekend before last, I came across an article, “17 Honest Photos of the ‘Embarrassing’ Sides of Depression We Don’t Talk About“, and it kind of shook me to my core. It was like holding up a mirror to the life I’d been living for the last 2.5 years. I was not prepared for that. I don’t think anything could have prepared me for that. I really had no idea how common this was or what it looked or felt like for others. Isn’t that always the way, though? We think we’re so weird or wrong that we can’t imagine our experience being common/normal.

Basically, when I moved into my current place it was right after some serious trauma and everything just sort of stopped for me, mentally. Moving back to the town I grew up in and experienced the worst trauma of my life (physically and emotionally abusive relationship from ages 14-19), I was frozen in time in a sense. So I never truly unpacked except necessities. I left boxes out on the patio, at first under a canopy but later that got shredded by the elements, as did my boxes, and finally the neighborhood rodent society took refuge.

My small studio in-law unit remained as it was when I moved in, half unpacked, some things very much randomly plunked, and my life continued around these obstacles without acknowledging them. This was fine at first, I kept the place reasonably tidy, which was easier with everything in boxes. But soon those boxes became bigger obstacles, items spilled out, or the boxes deteriorated. At first I was holding out for my landlord to affix my large bookcase to the wall before I filled it, living in earthquake country, but that never happened.

It felt like one thing after another kept me from settling into my lil’ shack (no hate, I love it, honestly) and while my life continued on with new people and jobs and troubles and so forth, my ability to keep it tidy fell away completely. I started to tell my then boyfriend not to come over anymore, that I was too ashamed of the mess but unable to tackle/manage it on my own. He never understood, but at least had compassion for my situation. The thing is though, I never attributed this combination of feeling overwhelmed and yet unable to do anything with my mess of a house to my anxiety and depression. The mess also never was as bad as it is now, or has been the last year.

A year ago my long term boyfriend and I broke up. I was in the midst of rearranging and organizing some things I’d been putting off when it happened. He’d even bought me a new gorgeous set of dishes with butterflies on them. I said I didn’t want to take them out of the box until my house was tidy again. Those dishes are still in their original box. They are too beautiful to live in my space as it is now. I long for the day where I can have a friend over and cook for them using these lovely dishes on the table.

It is very difficult to explain the feelings involved in all of this, but I can tell you that everything in that article rang true for me. The worse my “mess” got, the more overwhelmed I felt, the more I felt unable to deal with it…on top of the usual injury/pain issues I have (spine, knee, one foot), depression is exhausting and it hurts, too. I felt trapped in a semi-catatonic state almost. I just felt helpless and stuck in a really terrible and shame filled way.

I thought I was coping and appeared fine, and I did. No one was the wiser until anyone mentioned coming over to my place and my stomach would knot instantly. I would fluff it off as being inaccessible (it sort of is), too small for company (not a lie), or whatever else was going on in my life at the time. I told my 3 closest friends, but one lives many states away, the other two live very much in a messy state as well, though are always willing to help out. But I can’t accept help, nor ask for it. The thought of someone having to sift through my mess makes me feel ill.

I grew up in this state of mess, sometimes worse, but the realization of this came a couple of months ago. I had lost my job and thought to myself that while I have the time to job hunt I could also make time for getting my place together. My sights were not set high, I am okay with my usual bit of clutter, but I had a moment where I looked around and I was surrounded by recycling and I realized that this combined with many clothes hampers full of clean clothes looked an awful lot like my childhood squalor-filled home. It sucked the wind from my sails entirely.

Then sometime in November I had a few days of what professionals might call mania but it just felt like finally having the energy and focus to tackle something (ANYTHING!) and actually got rid of a lot of stuff. Like 12 garbage bags full! It was recycling guilt that kept the cardboard boxes of all shapes and sizes piling higher on my kitchen table. But then disposing of everything was difficult. My landlord’s home only has one very small trash bin and one regular sized recycle bin. So, I went into stealth mode! Ha-ha!

I felt a great sense of relief after this, but then soon found depression taking over entirely once again, just in time for the loneliest holiday season of my entire life. I truly felt like I was on a deserted island for about a week solid. It got rough. I was not my best self nor even a decent friend to myself. I reached out but no one seemed to be around or maybe didn’t know how to be supportive, who knows. Then after the new year I kicked my job hunt into into the highest gear ever and ended up in a whirlwind of non-stop interviews for nearly a month solid. I lost my voice several times.

I know this isn’t the best version of myself. I know I deserve to live in a space that I’m proud of and can look after on my own. I have lived in many other places with roommates and partners and have never had it get like this. I keep telling myself that I just need one big reset and then I can start fresh and keep it up. I even paid a woman last year to do just that, but after 3 hours and $300 she’d really only hung up most of my clothes and gathered things into bags (which honestly made a lot of things worse).

Shame is such a powerful and terrible thing to live with. People have told me that they always thought I was fancy or well-off, dates have called me intimidating, and all of this leaves me so confused. If they knew where and what I came from, if they knew the way I live now, they’d never think those things of me. Coping is a serious endeavor and for survivors of long-term abuse, to those who live with PTSD their entire lives, you cope without realizing. You present yourself in ways to appease and please others automatically. You keep secrets from everyone without trying, without even knowing sometimes. It takes a lot of fucking self work to acknowledge and process and work through and maintain. I have been on this path for over twenty years and was doing pretty fucking great, actually, until I moved back to my hometown.

After reading that article I didn’t leave the house for 3 days. I was in shock. I felt as though the curtains of my shame had been ripped away, exposed to the world. Then I went back to work at my new job and tried to be okay with everything until I couldn’t. Last week I reached out to a company that assists hoarders with removal and organization. This was so difficult for me to do. To open myself even mentally to the outside world like that, but I trusted that this was an org that specialized in this unique service and understood the needs for both me and my place. I know I’m not a hoarder, but thought the basics would align in what I needed in the end. Unfortunately no one ever got back to me and that’s probably fine. I am certain I couldn’t afford it anyway.

I will be reaching out to my healthcare provider once my coverage has begun. I have decided that I should explore the option of antidepressants. My previous thoughts and feelings on the subject have changed and while I am very much averse to ongoing unnecessary medication, this feels too important to not at least try. It is terrifying, I’ve never even had therapy for my various mental health concerns, but I also don’t believe I need the traditional talk therapy setting now. I have done the work and research in that realm for the last 20+ years and feel very capable and supported emotionally. But if there’s a chance that I could feel as I did those few days in November, where I had the energy and focus needed to get my house together, for longer than just a few days, I need to find out. If I can improve my quality of life at home I know it will allow me to excel in my career and personal life, too. I deserve the chance, at the very least.

Once I get a few paychecks, my first coming tomorrow, I can pay someone to haul away the damaged stuff on the patio at least. You’d be surprised how much such a thing costs, as I was when I first called 1800gotjunk to take the stuff away in November, only for them to take 1/3rd of it for $200 (they wanted $750 for all of it, but I was out of work and the $200 maxed my only credit card). It would be nice to use the outdoor table and chairs when the weather warms up again. I would love to have my bffs over for card games, or my dance partner for rehearsals and you know, just dinner.

I am trying to see my new job as a new leaf, a new start sort of, in the sense that I’ll be making a bit more than my last job and a helluva lot more than unemployment was providing, so I can pay for things I’ve put off (like puggo’s overdue vet exams and vaccinations) and hire help for my mess…hopefully. I don’t even know what would have happened if my unemployment had continued on as it did two years ago. I was already close to the brink, as it were, after only three months.

If you’re reading this and you relate, please say so. If you’re reading this and you know how I can get the support I need to get my place together, please say so. If you don’t have these issues or know what orgs can assist, but you have deep sympathy for this situation, please say so. So much of our lives is spent afraid of saying something. It feels so lonely not knowing that so many others in the world are in the same situation. It doesn’t have to be this way.

I will say that despite all of this, I do have a life full of love from great friends who are patient with me and kind, always. I have not spoken so openly about this before now, but that was the shame hanging over me. It’s still there, but beginning to feel just a little less heavy. I’m quite certain that the cause of the state of my childhood home being in such disarray is the same reason I’m living like this now. I know my bio-mom was always mentally ill. It’s one (of many) reasons why I didn’t think I wanted to reproduce. I never thought I would return to my hometown nor the state of the living conditions I grew up in. I hope I can move past this period of my life and onto brighter days and nights, cozy and warm, snuggled up with my puggo, in peace.

Rad Fatty Love to ALL,
<3
S

P.S. Check out and use the hashtag: #FatAndFree on Insta & FB!
And my hashtag #DateMyDamnSelf on Instagram if you feel so inclined

Donate to this blog here: http://ift.tt/2zKvPnQ

My blog’s Facebook page for things I share that aren’t on this blog (and updated daily): http://on.fb.me/1A18fAS 

Or get the same “shared” content on Twitter: @NotBlueAtAll

I also have an Instagram I’ve finally started to actually use: http://ift.tt/1NpWevR

And as always, please feel free to drop me a line in comments here or write me an email, I love hearing from readers. (Tell me your troubles, I don’t judge.): notblueatall@notblueatall.com



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Sunday, 25 February 2018

Perceiving the Beauty of All Bodies

defendI just got back from giving four days of talks at Smith, Amherst, Mount Holyoke, and UMass Amherst. The students, faculty, staff, and community members I had the honor to meet were absolutely amazing and I had a blast. (I also got to see and walk through snow – it’s possible I was the only one who was happy about that part!)

During one of my talks – The World is Messed Up, You Are Fine – I talked about beauty. In particular I talked about the ways that the diet and beauty industries leverage the idea of beauty for profit, in the process disempowering well, just about everyone.

I also talked about the idea that, rather than the suggestion that “beauty” is limited to certain people, the truth is that perceiving beauty is a skill set – which is to say that everyone has inherent beauty, and the ability to see that beauty is a skill that can be learned and expanded. Some people have never bothered to expand their skill-set beyond the stereotypes that we get spoon-fed. Stereotypes that are too often grounded in privileged identities in our culture like whiteness, thinness, appearing cisgender, heteronormativity, appearing able-bodied, and more.

Now, regardless of how we think of beauty, let’s be clear that nobody owes anybody else beauty or attractiveness by any definition. And there are plenty of other ways to deal with toxic beauty culture, including deciding that beauty just isn’t something that we should care about/talk about/value. I like the idea of perceiving beauty as a skill-set because it acknowledges that people around the world have the ability to appreciate many different types of beauty, and it puts the responsibility where it belongs – on the person who is doing the perceiving, not on the body that is being perceived. So if we can’t see the beauty in someone, that’s on us because there is nothing wrong with the person we’re looking at. And if someone can’t see our beauty – that’s on them because there is nothing wrong with us.

Now, if we don’t have a great skillset for perceiving beauty, that’s not exactly a galloping shock – we live in a society that lies to us early and often about beauty for reasons including profit and power, and media that makes it nearly impossible for us to even see people who fall outside the Hollywood stereotypes of beauty in any kind of positive light.

What we can do is take responsibility for expanding our skill-set. I think a good place to start is to notice when we can’t see the beauty in someone, and ask ourselves why. We can start by asking ourselves if it’s tied to an identity or characteristic that is marginalized in our society – this could be anything from racism/colorism to things like gendered ideas of height, or sizeism and more.

Regardless of where the idea came from, we can actively work to overcome our conditioning and see the beauty in bodies like these. One option is to create a powerpoint or other slideshow and add pictures that represent the types of beauty that we are struggling to see. Then go through the deck each day and work to see the beauty in each person. As you see people in your daily life, work to perceive their beauty (though, of course, please don’t visit your issues on them – this is about your own growth.)

I got an e-mail from one of the students who was at my talk that I wanted to share with you (with their permission.)  They wrote:

I wanted to thank you for what you said about perceiving beauty. I’ve never thought about it like this before. I’ve been forcing myself to really be aware of the thoughts I have and I’ve realized that even though I’m committed to social justice, I’ve been couching a lot of bigotry in my ideas of beauty. Like, I am clear that these folks should not be oppressed, and I fight against their oppression, but I still believe that their appearance makes them less…attractive…worthy…something not good. Anyway, it’s already created a big shift for me, and it has the bonus of making me feel much more confident myself since I know that even if someone doesn’t see my beauty, that doesn’t mean that it isn’t there. You are my shero, your whole talk was amazing and I learned a ton, but this has really stuck out so I wanted to tell you.

So there are lots of reasons to take responsibility for our ability to perceive beauty. When it comes to fat bodies, people who can’t see our beauty have plenty of options, one of them is to accept responsibility for their inability to see our beauty and to work on that. Regardless, we are never under any obligation to buy into sizeist (or any other negative) ideas about our bodies.

Like this blog?  Here’s more cool stuff:

Become a Member! For ten bucks a month you can support fat activism and get deals from size positive businesses as a thank you.  Click here for details

Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

I’m training for an IRONMAN! You can follow my journey at www.IronFat.com

If you are uncomfortable with my offering things for sale on this site, you are invited to check out this post.



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Friday, 23 February 2018

Update: Good News!

I got a new job! I started two weeks ago and I love it! I’m the office manager for a tech startup in the heart of silicon valley. In the short time I’ve been there I’ve received such great feedback from everyone and have already started to sass ’em, too! It’s challenging and different every day. I’m hosting a happy hour to hopefully get people mixing and mingling more, we have a lot of new people, not just myself. I’ll be making a pitcher of a spruced up gimlet (gin, lime, simple syrup – maybe soda?) with pineapple juice and fresh sage. Pretty stoked about it, too!

I’m truly excited to have a role where all of my skills will be utilized and recognized. Any support role is often thankless, but when it’s for good people (I hope, too soon to tell, right? Ha-ha!), it doesn’t feel that way. Sure, I’m in the honeymoon phase and have been burned by how many startups now?! Ha! I’m trying to look on the bright side, it takes effort, but seems worth it.

It is such a relief to be working again. Once paychecks start coming in I’ll truly feel a heavy burden lifted. I’ve been working on grown-up things like debt consolidation, taxes, and reaching out for help when I need it. It doesn’t really seem to get easier, but here the hell we are. We all just keep on keepin’ on. I’m glad that we do!

Also, I’m in love with this City Chic dress I snagged on eBay for a steal! I couldn’t get a decent full body shot to share, but he’s a selfie so you can see the lovely print (and my eyebrow showin’ off!).

Today I used a favorite fashion hack of mine. I have this high-low, babydoll cut, tunic-length top from Torrid that I adore. But the scoop neck combined with heavy-ish fabric and button front makes for some inappropriate wardrobe malfunctions. It’s either mega cleavage or hello bra staps. So I grabbed my handy dandy dollar store duct tape and rolled it around my bra strap (sorta like you would do to hang something up like a flyer or poster) and then just firmly stuck my top to it in a position that worked best for my purposes, and that sucker didn’t budge all day!

Image is of black bra strap with white horizontal pinstripes with a piece of duct tape rolled onto itself

I’m sure it’s nothing new to the world, but it’s little things like that, when off the rack fashion always leaves sizing and fit to be desired, that make me love my wardrobe even more. Do you have a favorite fashion hack of a similar nature? I’d love to hear all your tips! Hearing a few people mention my unique style recently gave me a little boost. But it’s also great to work somewhere I can dress as up or down as I want. I’m utilizing dresses and tops I haven’t been able to in ages. Woo!

I miss writing but needed a serious break from the topics I was writing about here. While necessary for me to get out at the time, it forced me to process some things that I guess I wasn’t entirely prepared for. I was also deep in my job hunt jungle, interviewing every weekday for three weeks solid. It was so exhausting. I’m so glad to have a break from that. I hope I can get back to writing again.

Tell me what’s new with you in the comments section below. I hope you’re well and I’m glad you stopped by.

Rad Fatty Love to ALL,

<3
S

P.S. Check out and use the hashtag: #FatAndFree on Insta & FB!
And my hashtag #DateMyDamnSelf on Instagram if you feel so inclined

Donate to this blog here: http://ift.tt/2zKvPnQ

My blog’s Facebook page for things I share that aren’t on this blog (and updated daily): http://on.fb.me/1A18fAS 

Or get the same “shared” content on Twitter: @NotBlueAtAll

I also have an Instagram I’ve finally started to actually use: http://ift.tt/1NpWevR

And as always, please feel free to drop me a line in comments here or write me an email, I love hearing from readers. (Tell me your troubles, I don’t judge.): notblueatall@notblueatall.com

 



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Fat As Fuck! (Podcast)

Hello!!!

I have something wonderful to share with you.

My BFF, Michaela and I have just launched a new podcast called, “Fat As Fuck” and I’m so excited to share it with you! We just released our first episode, so we get into the who and why and what our podcast is really about.

Here’s a teaser for episode one:

Fat As Fuck Episode 1 TEASER

I hope you check it out, follow via your preferred social media and podcast apps, and let us know what you think and what topics you’d like us to explore. We’ve been friends for ages and if you’re reading this it’s semi-likely you’ve already heard her voice on my first podcast for this blog years ago. We laugh a lot and hope you’ll be laughing along with us.

Rad Fatty Love to ALL,

<3
S

P.S. Check out and use the hashtag: #FatAndFree on Insta & FB!
And the hashtag #DateMyDamnSelf on Instagram if you feel so inclined

Donate to this blog here: http://ift.tt/2zKvPnQ

My blog’s Facebook page for things I share that aren’t on this blog (and updated daily): http://on.fb.me/1A18fAS 

Or get the same “shared” content on Twitter: @NotBlueAtAll

I also have an Instagram I’ve finally started to actually use: http://ift.tt/1NpWevR

And as always, please feel free to drop me a line in comments here or write me an email, I love hearing from readers. (Tell me your troubles, I don’t judge.): notblueatall@notblueatall.com



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Friday, 16 February 2018

Lies About Health At Every Size

Public HealthI see a LOT of misinformation being spread about Health at Every Size, sometimes by well-meaning but misinformed people, sometimes by those intentionally trying to discredit the concept. So today I thought I would repost this to help clear up some of what I think are common misconceptions:

1. Health at Every Size says that if you love your body you will be healthy

First of all, “healthy” is complicated to define. More to the point health – by any definition – isn’t an obligation, barometer of worthiness, entirely within our control, or guaranteed under any circumstance. To me, HAES on a personal level is about putting the focus on habits and behavior that support our personal health concept (rather that putting the focus on trying to manipulate our bodies to a specific height/weight ratio.)

It’s also about acknowledging that we don’t have as much control over our health as we might like to think we do, and creating environments that are conducive to health, and I don’t mean fat-shaming and soda taxes, I mean creating environments that are free from stigma and oppression, removing barriers to access and information, making healthcare accessible and affordable for everyone, giving people the option to appreciate their bodies and think of them as worthy of care.

Finally, everyone has the option (though, of course never the obligation) to love their bodies regardless of “health” or anything having to do with “health.”  People are allowed to having complicated feelings when it comes to their bodies and “health.”

2. Health at Every Size is only for fat people

Nope-ity nope.  HAES is practiced by people of all sizes.  The reason that it’s most often talked about in conjunction with fat people is that fat people are typically told that the only path to health is to become thin (despite the fact that there are thin people who have all the health issues that fat people are told to lose weight to avoid) and so while many fat people find it while looking for an alternative to the intentional weight loss recommendations that have been failing us our entire lives, HAES is an option for those who want to pursue health rather than body size manipulation, it’s also practiced by people of all sizes who want an evidence-based health practice.

3.  Good Fat People Practice Health at Every Size 

The good fatty/bad fatty dichotomy is the idea that fat people who participate in “healthy” behaviors or are “healthy”  (as defined by the person who inappropriately and incorrectly thinks that it’s their right to judge) are better than the “bad fatties” who don’t practice “healthy” behaviors or aren’t “healthy” (by whatever definition.)

The GF/BF dichotomy is wrong and it needs to die.  Each person should have the right to define and prioritize “health” for themselves, and to choose the path that they want to travel -those are personal decisions and aren’t anyone else’s business (those wishing to make a “but muh tax dollarz!” argument can head over to this post) Public health isn’t about making fat people’s health the public’s business, or about creating healthism in the name of health, or about using “health” as a thin veil for fat bigotry.

4. I disagree with the science behind Health at Every Size, therefore I am justified in treating fat people like crap.

Noooooooo. World of no. Galaxy of no. Universe of no. No. People are free to believe whatever they want about body size and health. None of those beliefs are a “get out of Sizeism free” card.  Fat people have the right to exist without shame, stigma, bullying, or oppression. Period.  What someone believes, or what is true, about Health at Every Size does not come into play here.

The seed for my HAES journey was reading the research about weight loss methods and realizing that there wasn’t a single study that would lead me to believe that future efforts at long term significant weight loss would have any different outcomes from my past attempts (which is to say, I had the same experience as almost everyone – losing weight short term and gaining it back long term, often plus more!)  Realizing that I had been sold a (massively profitable) lie about my size and health, I went looking for what the research actually said. And the research seemed pretty clear to me that, understanding that my health wasn’t entirely within our control, a focus on behaviors rather than body size was a much more evidence-based way to support my health.

There are people out there riding the weight loss roller coaster even though their experience, and the research, tells them that there is no reason to believe that attempting intentional weight loss will leave them thinner or healthier in the long term, because they want to be “healthy” and they don’t know that there is another option.  HAES is important because it provides a paradigm for personal choices and (perhaps more important) wellness care that doesn’t revolve around doing something that nobody has shown is possible for an outcome that nobody has proven is valid.

Like this blog?  Here’s more cool stuff:

Become a Member! For ten bucks a month you can support fat activism and get deals from size positive businesses as a thank you.  Click here for details

Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

I’m training for an IRONMAN! You can follow my journey at www.IronFat.com

If you are uncomfortable with my offering things for sale on this site, you are invited to check out this post.



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Sunday, 11 February 2018

Cinderella VBACs and Gestational Age

Image: Disney

"At my last doctors appointment I went in and asked my doctor if I could continue with the pregnancy past 40 weeks if I were still pregnant. He said No because the risk of uterine rupture goes up past 40 weeks."  source
"Gestational age greater than 40 weeks alone should not preclude Trial of Labor After Cesarean." ACOG 
Many women planning a VBAC (Vaginal Birth After Cesarean) are told by their providers that they will be supported for a VBAC, but their doctors often conveniently forget to mention ahead of time that they enforce arbitrary rules that require women to go into labor by 40 weeks or be forced into a cesarean, like the woman quoted above. Some even insist on a repeat cesarean by 39 weeks.

This is what author Henci Goer calls a "Cinderella VBAC." The doctor claims to support VBACs, but puts so many limits on VBAC labors that almost no one gets one. Examples: the mother must go into labor before 40 weeks, the baby has to be below a certain weight, the mother must not gain very much weight in pregnancy, etc.

In that way, caregivers can give lip service to supporting VBACs without having to actually attend very many. As a result, activists separate caregivers into "VBAC Tolerant" versus truly "VBAC-friendly" by their insistence on these type of Cinderella VBAC restrictions.

Gestational Age Cutoffs in VBACs

One of the most common Cinderella VBAC rules is a gestational age cutoff. At 40 weeks, many women are told the risk for uterine rupture goes up so a VBAC labor would be too risky and they must schedule a repeat cesarean. However the research on uterine rupture past 40 or 41 weeks is conflicting and women are not being permitted to make fully informed decisions.

Some studies do show a modest increase in rupture risk by gestational age. However, others do not. One of the largest and most powerful gestational age studies did not show a statistically increased risk of rupture past the due date. This study was done at 17 different hospital centers, over a period of 5 years, and involved 11,587 women who labored for a VBAC.

What muddies the research waters is that many pregnancies after the due date end up induced, and a number of studies show that induction of VBACs is associated with more uterine rupture. So are the ruptures in these studies truly being caused by going beyond the due date, or is it an artifact of the high rate of inductions and augmentations done in pregnancies after 40 weeks? Some studies control for this and others do not.

In their book, Optimal Care in Childbirth (pg. 118), Henci Goer and Certified Nurse-Midwife Amy Romano note that the majority of uterine ruptures in these gestational age studies are found in the induced groups, and especially in those induced with an unfavorable cervix.

Now there is a new study just out on gestational age and rupture. It also found that the risk for uterine rupture did NOT increase with gestational age.

In this seven-year Israeli study of 2,849 women, 0.56% of women had a uterine rupture during a "trial of labor after cesarean" (TOLAC). The rate did not differ significantly by gestational age (GA), and  90% of women in the study had a VBAC. If all the women at 40 weeks had been forced to have a repeat cesarean, that would have been a lot of unnecessary cesareans. This study adds strong support to the position that women should not have to have a repeat cesarean at 40 weeks. The authors conclude:
Among women at term with a single previous cesarean delivery, GA at delivery was not found to be an independent risk factor for TOLAC success or uterine rupture. We suggest that GA by itself will not serve as an argument for or against TOLAC.
The latest guidelines from ACOG (the American College of Obstetricians and Gynecologists) note that gestational age beyond 40 weeks should not preclude laboring for a VBAC. This position is echoed by VBAC guidelines from other countries as well.

What About Inductions?

What about other options? To avoid going past 40-41 weeks yet still give the woman an opportunity at a VBAC, some caregivers will induce labor around the due date. They point out that in some studies the chance of a VBAC decreases after the due date so they hope that inducing at the due date gives the woman the best chance at a VBAC. They also point out that the risk for stillbirth, although quite low, does increase at some point after the due date.

However, induction at term has pros and cons. In most studies (but not all) induction of labor increases the risk for uterine rupture and decreases the chance of a VBAC. For example, the 2015 NICE guidelines from the Royal College of Obstetricians and Gynaecologists states:
Women should be informed of the two- to three-fold increased risk of uterine rupture and around 1.5-fold increased risk of caesarean delivery in induced and/or augmented labour compared with spontaneous VBAC labour.
In Optimal Care in Childbirth (pg. 118), Goer and Romano, noting that the majority of rupture cases that occurred after the due date were associated with induction, state:
These data suggest that women should not be induced for passing their due date. Induction both increases their risk of scar rupture and decreases the likelihood of VBAC. 
But how does induction of labor specifically compare with expectant management past the due date in VBAC women?  Recent research suggests that induction increases the risk for uterine rupture (1.4%) as opposed to expectant management (0.5%). In other words, caregivers' interventive management of women past the due date actually increased the risk for harm, not reduced it.

This is not to say that induction and augmentation should never be used in VBAC labors. Sometimes induction is medically necessary. Used carefully, induction and augmentation can be used safely in some VBAC labors. It doesn't have to be all or nothing.

Some types of VBAC inductions probably carry more risk than others, though. Some research suggests that prostaglandin use, sequential use of prostaglandins and pitocin, the induction of women with an unripe cervix, and the induction of women without a prior vaginal birth may raise the risk for uterine rupture.

For sure, misoprostol (PGE1) is associated with much higher uterine rupture rates and should never be used to induce a woman with a prior cesarean. The risk with other prostaglandins (PGE2) is less clear, though most clinicians avoid them these days.

Currently, the most favored method for inducing a VBAC is by mechanical means, such as amniotomy (breaking the waters) or a transcervical balloon catheter, along with oxytocin augmentation if needed. These methods may be less risky than other methods of induction for VBAC moms, although they still carry more risk for uterine rupture than spontaneous labor.

In other words, all induction scenarios do not carry equal risk. The risks may not be as high for induced labors in women with a very ripe cervix or with a prior vaginal birth, but parents should remember that the risk is never zero.

Although induction tends to lower the probability of having a VBAC, many women are induced and do have VBACs. This seems especially true for women with a high Bishop's Score (indicating a ripe cervix) or a previous vaginal birth. Regardless, the majority of women who have been induced do have VBACs. In several recent studies, about one-half to two-thirds of induced labors ended in VBAC. That's a lot of repeat cesareans averted.

Induction is a decision that should not be taken casually but which can be a legitimate choice for some. However, induction is generally overused in VBAC labors, and is often undertaken without fully apprising women of the risks associated with it. But it does remain a viable choice and there are women who have had induced VBACs.

Summary

When a woman with a prior cesarean passes her due date, there are many courses of action that are possible. Every choice has benefits and risks. Although the vast majority of women with a prior cesarean will have good outcomes whatever they choose, there are unique pros and cons to consider.

The most logical choice is to let nature take its course and wait for spontaneous labor. Many caregivers are very supportive of waiting for spontaneous labor after 40 weeks in women with a prior cesarean, and many will wait until after 41 weeks or even later to start discussing alternatives, as long as mother and baby are doing well. Obviously, each case's unique circumstances must be considered.

On the other hand, a surprising number of caregivers still use gestational age restrictions and force either repeat cesarean or induction at 40 weeks. For some, this is out of fear of any possibility of increased risk of rupture or a fear of stillbirth. For others, it is out of a mistaken belief that after 40 weeks, there is little chance of a VBAC. A cynic would also note that since about half of women do not go into labor before their due date, gestational age restrictions also mean that doctors attend fewer VBAC labors, easing their schedules while still letting them appear to be supportive of VBACs.

Unfortunately, research does not offer 100% clear guidance on uterine rupture risk after 40 weeks. Some research suggests a somewhat increased risk, but a closer look suggests the risk is mostly in induced labors or the difference is quite modest. The strongest research does not show an increased risk after the due date at all.

Gestational age restrictions also bring up the question of ethics. Mandating a repeat cesarean or an induction at a certain gestational age is a high-handed and paternalistic approach. It infantalizes women and strips them of their autonomy to make their own medical decisions. It also ignores the possible harms associated with these interventions.

Instead, women should be counseled about the pros and cons of each choice. Caregivers may advise a certain course of action, but in the end the woman has the right to accept or refuse that course of action. Discussion of these issues should begin early in pregnancy, not at term, so there is plenty of time for decision-making. Remember, every choice has pros and cons.

Repeat Cesarean without labor
Pros: Convenience of scheduling; lowest risk for rupture; no uncertainty of labor
Cons: All the risks of surgery and surgical recovery (bleeding, pain, infection, blood clots); more breathing problems for the baby; more breastfeeding problems; substantial risk of life-threatening placental issues in future pregnancies
Expectant Management past due date
Pros: Spontaneous labor is usually easier/less painful and VBAC is more likely; baby is more ready for life outside the womb (less problems with breathing, breastfeeding, blood sugar levels, bilirubin levels); mother usually has an easier recovery
Cons: May labor and still end up with a cesarean; continuing the pregnancy entails the very small but real risk of stillbirth or uterine rupture; may still need to have induction of labor at some point, may have decreased chance of a VBAC (although this may be influenced by high induction rates later)
Induction of Labor at 40 or 41 weeks
Pros: Induction can be scheduled and planned for; most of the time induction still ends in a VBAC; induction means predictable staffing requirements for the hospital
Cons: Induction involves a harder labor and more need for pain relief; more risk for fetal distress; a significantly increased risk for uterine rupture; and typically a decreased chance for a VBAC. May still end up with another cesarean after labor
Clearly, there are no easy answers. No one answer is the right answer for all women and situations.

The most important take away here is that after the due date, women with a prior cesarean should not be forced into anything; they should have choices. The pros and cons of the various choices should be reviewed with the mother and the ultimate choice should be left up to her. 

At term, some women will choose repeat cesarean, some will choose induction, and some will choose to wait for spontaneous labor. All are valid choices.

The ACOG guidelines are clear and caregivers need to honor them. Gestational age past 40 weeks should not be used as a cut-off to keep women from laboring for a VBAC.

Women who want a VBAC should ask careful questions early in pregnancy about the guidelines of their providers, including whether there are gestational age cutoffs or other limitations on their options. Be proactive; don't wait until the last minute to find out. In some cases, women may need to switch providers in order to get a truly VBAC-friendly provider. It is possible to do so, even late in pregnancy, but the process is easiest when it's done early.

The time is at hand. All women deserve to go to the ball if they want to. "Cinderella VBACs" need to become a thing of the past.

Checklist originally from Melek Speros


References

Arch Gynecol Obstet. 2018 Jan 22. doi: 10.1007/s00404-018-4677-9. [Epub ahead of print] Trial of labor following one previous cesarean delivery: the effect of gestational age. Ram M, Hiersch L, Ashwal E, Nassie D, Lavie A, Yogev Y, Aviram A. PMID: 29356955
PURPOSE: To stratify maternal and neonatal outcomes of trials of labor after previous cesarean delivery (TOLAC) by gestational age. METHODS: Retrospective cohort study of all singleton pregnancies with one previous cesarean delivery in TOLAC at term between 2007 and 2014. We compared outcomes of delivery at an index gestational week, with outcomes of women who remained undelivered at this index gestational week (ongoing pregnancy). Odds ratios and 95% confidence intervals were adjusted for maternal age, previous vaginal delivery, induction of labor, epidural use, presence of meconium, and birth weight > 4000 g. RESULTS: Overall, 2849 women were eligible for analysis. Of those, 2584 (90.7%) had a successful TOLAC and 16 women (0.56%) had uterine rupture. Those rates did not differ significantly for any gestational age (GA) group. Following adjustment for possible confounders, GA was not found to be independently associated with adverse maternal or neonatal outcomes. CONCLUSION: Among women at term with a single previous cesarean delivery, GA at delivery was not found to be an independent risk factor for TOLAC success or uterine rupture. We suggest that GA by itself will not serve as an argument for or against TOLAC.
Obstet Gynecol. 2005 Oct;106(4):700-6. Safety and efficacy of vaginal birth after cesarean attempts at or beyond 40 weeks of gestation. Coassolo KM, Stamilio DM, ParĂ© E, Peipert JF, Stevens E, Nelson DB, Macones GA. PMID: 16199624 
OBJECTIVE: To compare rates of vaginal birth after cesarean (VBAC) failure and major complications in women attempting VBAC before and after the estimated date of delivery (EDD) METHODS: This was a 5-year retrospective cohort study in 17 university and community hospitals of women with at least 1 prior cesarean delivery. Women who attempted VBAC before the EDD were compared with those at or beyond 40 weeks of gestation. Logistic regression analyses were performed to assess the relationship between delivery beyond the EDD and VBAC failure or complication rate. RESULTS: A total of 11,587 women in the cohort attempted VBAC. Women past 40 weeks of gestation were more likely to have a failed VBAC. After controlling for confounders, the increased risk of a failed VBAC beyond 40 weeks remained significant (31.3% compared with 22.2%, odds ratio 1.36, 95% confidence interval 1.24-1.50). The risk of uterine rupture (1.1% compared with 1.0%) or overall morbidity (2.7% compared with 2.1%) was not significantly increased in the women attempting VBAC beyond the EDD. When the cohort was defined as 41 weeks or more of gestation, the risk of a failed VBAC was again significantly increased (35.4% compared with 24.3%, odds ratio 1.35, 95% confidence interval 1.20-1.53), but the risk of uterine rupture or overall morbidity was not increased. CONCLUSION: Women beyond 40 weeks of gestation can safely attempt VBAC, although the risk of VBAC failure is increased.



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Sunday, 4 February 2018

Immigrants and Bikes

I’ve seen the argument that DACA recipients are like “kids whose parents stole a bike and think they should get to keep it.” I think that’s a flawed analogy for many reasons.

But, let’s say that your parents acquired a bike in violation of some criminal or civil law. This includes kids whose parents stole the neighbor kid’s bike at gunpoint, parents who bought the bike not knowing that it was stolen, and parents who received the bike in compensation for work, were therefore supposed to pay taxes on it, and didn’t (some deliberately, some who honestly forgot or didn’t realize). The whole range of major to minor offenses, both criminal and civil, both deliberate and inadvertent.

Whatever your parents did, you had no control over it. You may have known that something was shady about your bike, or you may have been blissfully unaware. You just got a bike. With that bike, you got a paper route when you were 10 or 12. From that paper route, you built up some savings. Later, at 16, you used the bike to commute to your part-time job at the grocery store. You kept saving and eventually bought an adult-size bike, which you still ride. You went to college or trade school. Your paper route and grocery wages didn’t pay for the whole thing, of course, but they helped. And that second bike saved you an awful lot of gas money while you were in school. Even if you’d paid for the second bike another way, you probably wouldn’t have had the confidence or skill to bike commute in college, if not for all that time you’d spent on the first bike as a kid.

You get a job and start building an adult life. Maybe you get married and have kids, maybe it’s just you and your cat. Maybe you buy a house.

One day, a government official comes to your door and tells you that because of the way your bike was acquired, it’s now forfeit. Your second bike, which you still have and ride, is also forfeit. In fact, all of your assets are going to be taken by the government, regardless of their relationship to the bike. You have a choice. You can leave your current hometown, job, friends, and family, and start your life over from scratch with nothing. Or, you can go to jail. Indefinitely. Eventually, maybe after several years, you will have the chance to explain to a judge why you should not have everything taken from you and get to stay where you currently live. Because you yourself aren’t being charged with a crime, you have no right to a lawyer.

Regardless of the crimes or civil offenses committed by the parents, or when the child became aware of them, is this a just and reasonable punishment? Because that’s what we do when we deport people.



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