Stigma perceived by overweight women.

OBJECTIVE
to understand the experience of discrimination perceived by overweight women.


METHODS
a qualitative research conducted at an outpatient clinic in Salvador, Bahia, where eleven women were interviewed. The interviews were transcribed and submitted to thematic content analysis.


RESULTS
the analysis of the statements expressed three categories: Suffering discrimination in different social contexts: denounced disrespect, hostility, veiled and/or explicit exclusion, prejudice, injustice and insults lived in public transport, at work, in the family environment, in social events and commercial establishments; Experiencing negative feelings about discrimination: revealed inferiority, sadness, shame, fear, anger, frustration, low esteem and discouragement faced by women; Reacting to discrimination: expressed isolation of marital intimacy and social encounters, removal from work, concealment of body and feelings and even illness of women.


FINAL CONSIDERATIONS
the discrimination experienced in various settings has caused suffering, embarrassment, negative feelings, shame, isolation and loss in women's lives.


INTRODUCTION
Overweight has been considered one of the biggest public health problems in the world and stands out for being a major risk factor for a number of chronic diseases (1) . However, the damage caused by obesity goes beyond the biological consequences (high blood pressure, diabetes mellitus, cardiovascular disease, musculoskeletal problems and cancer) as it is a complex condition that adds to a range of psychosocial repercussions (2) .
The number of overweight and obese people in low-and middleincome countries is increasing, particularly in urban settings (3) , as is the concomitant increase in stigmatization and discrimination associated with the disease (4)(5) . In contemporary Western society, body weight is an important attribute of physical appearance and has been a source of perceived discrimination with a close prevalence of racial discrimination (6) . As one of today's most stigmatized health conditions, obesity makes obese individuals more likely to suffer from low self-esteem than thinner people (7) .
Stigma is a derogatory attribute and refers to an association between attributes and stereotypes. It is established in the social relationship in a way that a certain trait of the individual imposes itself on the social relationship, distancing others from this relationship and preventing them from paying attention to their other attributes (8) . It comes from "preconceptions" that are transformed into normative expectations in a social group and refers to a trait considered socially impure that makes a person strange, depreciated, undervalued, and less desirable. Thus, it has deleterious consequences for the individual, modifying the social process of developing self-concept construction, interpersonal relationships and self-esteem. The overweight subject experiences in daily activities experiences of isolation, labeling and discredit, dimensions that characterize the stigma (8) .
In modern society, the stigma attached to body fat is an undesirable social and moral construct that disqualifies subjects, as negative attributes are imputed to them because contemporary representations of beauty do not fit (9) .
The fact that the body image of overweight people is considered inadequate in various social contexts and is in dissonance with the "standards of beauty" imposed by the media has caused severe damage, including prejudice, discrimination and social exclusion (5) . Experiencing weight stigma can actually be detrimental to weight management and further promote weight gain, as stigmatized individuals may be less inclined to want to exercise in public and experience more stress (10) . Evidence indicates that weight stigmatization is a predictor of binge eating, weight regain and other risk factors (11) .
Prejudice, defined as an anticipated idea or concept without a serious or impartial basis, usually has an unfavorable connotation in relation to something or person (12) . In the case of obesity, in recent years there has been increasing attention to weight-related prejudice due to its deleterious potential depending on the context and the individual (13) . Prejudice can cause psychosocial and economic problems such as reduced earnings and opportunities to enter the labor market (14) . Discrimination characterized by unequal or unfair treatment given to a person or group, based on prejudices of some kind, notably sexual, religious, ethnic (12) , has significantly affected people with obesity, especially women (15) .
With regard to care for people with obesity, the Scientific Societies Guidelines focus primarily on the clinical and therapeutic aspects of the disease. Although obesity represents a real threat to the integrity of the biological dimension and to the quality of life of the subjects, social aspects deserve the close attention of professionals due to the psycho-emotional repercussions that derive from this experience.
In this context, knowing how people with obesity experience discrimination, what they feel, think and the repercussions on their lives is relevant. In addition, it can help sensitize practitioners to think of ways to approach the problem to help them cope with this serious problem.

OBJECTIVE
To understand the experience of discrimination perceived by overweight women.

Ethical aspects
The project was approved by the Research Ethics Committee at Plataforma Brasil. Eligible women were informed about the research objectives, procedures adopted, right of withdrawal and confidentiality of personal identity. They signed the Informed Consent Form prior to the initial data collection of the parent project.

Type and place of study
This is a qualitative research developed in a reference outpatient service for the care of obese people in the city of Salvador, Bahia, Brazil, users of the Brazilian Unified Health System (Sistema Único de Saúde). This ambulatory has a multidisciplinary team composed of doctors, nutritionists, psychologist, nurses and undergraduate and graduate students in health.

Study participants
The eligible participants for this study were 35 women, enrolled and followed up at the outpatient clinic, who revealed that they had suffered discrimination or prejudice due to being overweight in the interviews conducted for the matrix research project entitled "Monitoramento Remoto de Enfermagem de Mulheres com Excesso de Peso". Of these, 11 returned for routine consultation during the project's term and were invited to speak more deeply about the experience of discrimination. Women who did not attend the service during the established data collection period were excluded.

Data collection
Data collection took place between August and September 2017. Data on sociodemographic characteristics such as age, skin color, education, family income and marital status were taken from the closed-ended instrument of the parent project.
To explore the object of study we used a script containing open questions such as "Tell about the experience of discrimination for overweight" and "Talk about the repercussions of discrimination of Stigma perceived by overweight women Palmeira CS, Santos LS, Mussi FC, Silva SMB. suffered". The researchers and the participants were approached in the consultations held at the outpatient clinic during routine visits. The interviews were conducted in a private practice by the doctoral researcher accompanied by a nursing graduate student from the 9 th semester of scientific initiation, lasted from 10 to 20 minutes and were recorded and transcribed in full.
The interviewees were identified by the letter "I" and numbered from 1 to 11, to preserve their identity. During the interviews, when some kind of suffering due to the discrimination situation was identified, the participant was referred to the service psychologist.

Data analysis
In the analysis of the statements, thematic content analysis was used (16) . Firstly, we proceeded to a thorough and exhaustive reading of the participants' statements to extract the nuclei of meaning. Once identified, we proceeded to group those that indicated the emergence of convergence. Through the comparison process, the identified nuclei were grouped by their similarities and differences forming the categories. After organizing the results into categories, the third step took place, the interpretation in the light of national and international literature.

RESULTS
The study group consisted of 11 women with a mean age of 40.8 years ranging from 29 to 56 years. One participant reported having white skin color, six brown and four black. As for education, one had until elementary school, nine until high school and one had higher education. Regarding marital status, six women were in a stable union and five had no partner. Only one had a family income exceeding three minimum wages.
The analysis of the statements allowed the formation of three thematic categories that expressed the experience of stigma: Suffering discrimination in different social contexts; Experiencing negative feelings about discrimination; and Reacting to discrimination.

Suffering discrimination in different social contexts
This category showed where and how the discrimination experienced by women occurred, revealing it in public transport, in the world of work, in the family environment, in social events and commercial establishments. It revealed that stigmatized and discriminated people quickly become aware of the way they are viewed by others.
In public transport, they suffered disrespect, hostility and veiled and/or explicit exclusion by employees and users as illustrated by the statements: Discrimination by aesthetic factors disrespected women' s principles and values and was constantly and gradually perceived in work environments. In certain situations, they suffered from unequal opportunities, because they did not correspond to the definition of beauty, the normal and the socially accepted standard of beauty. The participants of this study suffered discrimination in the world of work, both at the time of interviews for selection and while on the job, denouncing prejudice, injustice, social exclusion and insult by employers: In a beauty salon, you have to sit, but the chair may not support me. So, salon owners are afraid to put a fat on the chair and it cannot stand and will damage, having to have maintenance in the chair every month. I've put my resume in several places, never been called. When I personally gave the resume to the factory owner, he looked me up and down with that look, you know? There will be no clothes that will fit this person. Another fact that occurred last year when I went to interview at the mall. They asked if I was doing some kind of weight-loss treatment and told me to lose some more weight, then back because I was not yet the store profile. (I1) One of the moments was when I went looking for work. The person who interviewed me said I couldn't be on the board because the profile I wanted was not a fat person. She didn't give me the work, she liked my resume and everything, but because I was overweight, because I was chubby, I wasn't in the company profile. (I4) It was in a company that I worked for. When I got there the supervisor always discriminated against me "You fat, you're fat! You weren't supposed to be here, you're an orca. " I've been looking for jobs elsewhere and I couldn't, I think it was because of that, I got it in my head. I think the prejudice against fat people kept me from finding other jobs because they always said that to me. Then I got that in my mind. Elsewhere I went, everyone could, but when my time came, I couldn't. (I3) Prejudice starts with the company, because when I started working at this company my colleagues were all skinny. Then they were in that review "there will be no uniform for you". (I5)

I got fired because of my weight. (I1)
The family environment was also pointed as a space of prejudiced attitudes occurring labels, charges, censorship, disapproval, and humiliation: Other noteworthy reports were the negative reference to body weight made by the spouse and perceived by women as an attitude of discrimination, showing that they have a derogatory attribute that makes them different from others: My husband also sometimes looks at me a little differently. Looks at me very different indeed. The fact that you say "you're going to break the bed" has already arrived. (I1) My husband doesn't talk, but we feel. He likes Bahia a lot, so he says "I'm going to buy you a Bahia team shirt, will it give? For me, this is discrimination". (I5) Discrimination in diverse social contexts and in many ways has often occurred directly and at other times by subtle mechanisms of rejection. Prejudice and exclusion lived on the street and in social events are illustrated in the statements of women: Obesity influences, there are parties no one calls me to go to. I know a lot of people, but in social matters, to be able to go out, have fun, almost nobody calls. I used to call more, but nowadays, nobody calls because of prejudice. In commercial establishments, when looking for clothes to buy, were victims of jokes, contempt and prejudiced care. Several vendor approaches have anticipated the lack of women's size clothing, blaming them and offending them because of fat: There are always those little jokes. You go buy some clothes, go into a store and listen "There are no clothes for your body type, only for skinny, until number 44". People are not interested in serving you. She arrives at a store and wants to buy an outfit, she likes a dress, and they are already saying that she doesn't have clothes for her body size. Other than the jokes you hear "Why don't you lose weight?". (I11) I arrived at a store to buy an outfit on the exposed mannequin, then asked the saleswoman if she had size XL. She looked at me and said "No, we only work with size M.". "You don't have L, do you?", I asked. "No, you're too fat, that size we don't sell.", she said. (I9) How many times have I gone shopping for clothes and heard jokes in the store. I don't like to remember when I heard jokes in the store, so I was thrilled like that. Because when we remember we want to bury. (I4)

Experiencing negative feelings about discrimination
This category revealed feelings of inferiority, sadness, shame, fear, anger, frustration, low esteem and discouragement when discriminated in different social contexts by being overweight. Several statements were loaded with introjected stigmas such as a feeling of low value and low self-esteem that caused deep suffering. Thus, women internalized the depreciation attributed to them.

Reacting to discrimination
This category expressed women's behaviors and attitudes resulting from discrimination revealing harm and loss in various social contexts. The withdrawal of insertion in the labor market was a frequent reaction of women illustrated by the statements: It was observed ways of the stigmatized woman to relate to the situation that surrounds her. She may be or try to be relatively indifferent and suffer, but not change her behavior. Yet there is one that becomes self-insulated, insecure, and withdrawn. This second condition was expressed by some women and reinforced the introjected and perceived stigma: The marital relationship of some women was shaken due to arguments, shame and loss of horniness. The discrimination suffered led the woman to feel unwanted by her partner and to withdraw from intimacy:

I'm ashamed in those hours of being on, very ashamed. As much as he doesn't say anything, I'm ashamed. One day he even asked "Why do you just leave this light off?" But, I don't like it, I don't accept myself, I wasn't like that. Prejudice had an influence on my marriage. These are the things that hurt me. (I5)
The above statements revealed the reaction of hiding the stigma mark, that is, hiding the obese body, avoiding showing itself as a way to avoid a derogatory judgment of the other and rejection. The shame you feel is converted into something you should feel ashamed of. It is anticipated that something bad or embarrassing will happen again, based on previous discriminatory experiences, leading the woman to hide. Some statements highlighted another way for women to deal with discrimination. defending oneself, avoiding confrontation, keeping silent and hiding feelings:

To deal with situations of discrimination I prefer not to leave the place. I won't mistreat the person, but I can't handle this kind of biased person. (I7)
Women's experience reinforced that internalized stigma or self-stigma leads to social isolation and self-disapproval. There are women who have come to believe that they deserve to be discriminated against and mistreated as they look out of step with socially accepted standards. Thus, they seemed to develop a process of standardization and self-discrimination:

Prejudice influenced. I don't like looking in the mirror myself today. (I7)
Stigmatized and discriminated women self-monitored and felt guarded and thus developed strategies to hide the unacceptable attribute, excess body fat. The statements revealed the reaction of hiding the body from other people, avoiding derogatory judgment. Stigmatization occurred both by those who labeled and by women labeled: In the reports it was also noticed that the lack of acceptance of herself, the pain and suffering caused by discrimination led to women emotional instability, anxiety, crying and illness like depression: Reports of few women have made explicit attempts to better deal with discrimination after various confrontations, turning it into a life-long situation. However, in fragments of the speeches there was a behavior of "adaptation" to the discriminatory situation, attempts not to be let down. However, the suffering is permanent even because the memories of the lived situations present discrimination:

DISCUSSION
Current evidence suggests that stigma and weight-based discrimination increase vulnerability to psychological distress, which may contribute to worsening general health conditions. Stigmatization, constituted by the act or effect of marking someone by negative stereotypes, discriminating and prejudiced labels (8) .
In the health field, it relates to physical defects and diseases, including those that modify body image, as occurs in obesity.
Obesity is a highly stigmatized disease and there is evidence on the ways in which obese individuals experience biased treatment in different contexts of society, including social, educational, occupational and health environments, mass media and even interpersonal relationships (15) .
The narratives of the interviewees pointed to lived stories full of suffering resulting from the embarrassment to which they were exposed in public transportation. Some probably ordinary situations that affect obese people result from what they see or hear from others, such as laughter and "mocking" looks. The fact that the obese person is a victim of derogatory and discriminatory treatment shows the lack of preparation and sensitivity of society to address this issue. Weight stigma can lead to negative social attitudes, beliefs and self-criticism expressed about obese individuals (6) .
Public transport, which should guarantee the population's right to come and go, becomes a source of discrimination and embarrassment for the obese person, whether due to the difficulty of walking in narrow corridors, overtaking the turnstiles or seat. However, the legal protection against prejudice and discrimination of the obese person, as a social issue, is little addressed, either by the lack of effective implementation of public accessibility and equality policies, or by the absence of specific legal provision against discrimination (17) . In some states, the benefit of boarding and disembarking obese people in vehicles without the need to pass through the turnstile is already official (18) .
The workplace is one of the many areas of life where overweight people can be treated unfairly (15,19) and be at a substantial disadvantage before the interviewing process begins or when employment is maintained (20) . Society identifies them as lazy and even limits their operational performance (21) .
In agreement with the literature (15,(20)(21)(22) , the data found in this study show that the participants do not expose their professional skills and qualities, since the opportunity is vetoed at the moment the obesity condition is revealed. Reports with similar content regarding rejection due to overweight for hiring, including offensive comments by the employer are found in the literature (19) .
Anthropometric characteristics play an important role in the evaluation when the degree of attractiveness is considered in the selection process, especially when the candidate is a woman. In addition, overweight candidates have the worst results in job selection requirements, being ranked under lower employability conditions compared to non-obese candidates (23) . It is noteworthy that in Brazil, despite the high prevalence of discrimination by weight, there are no federal laws that directly prohibit this form of discrimination, making the entry and permanence of the person in the labor market a challenge.
Some testimonies also bring discrimination against family members, corroborating the literature that states that people with obesity are discriminated not only in the workplace, but also within the social group to which they belong, such as family, neighbors and friends (4) . The family who should be part of an obese person's support network sometimes becomes the source of discrimination.
The data found in this study reveal that while the obese person recognizes their condition as a disease, the same is not true of those around them, including misunderstanding of their difficulties or failures in therapeutic treatments. Obese people are often viewed by family and friends as unattractive, lazy, uncontrolled, unwilling, motivated and initiative to pursue weight loss, leading them to internalize these perceptions about themselves (24) . For society to understand and respect the problems faced by obese people, the approach of guilt by overweight victims should be extinguished, as this does not motivate them to lose it, and contributes to many adverse health consequences, including future weight gain (25) .
The participants' testimony about feeling embarrassed and rejected when hearing comments from their partner, shows that there is an insecurity with the body image that negatively influences sexuality. An individual who does not feel desirable may be deprived of a positive sex life. Healthy sexual function plays an important role in a woman's quality of life and when limited by a health problem, whether clinical or social stigmatization, can lead to mental and emotional disorders (26) .
Our findings indicate that women responded to discrimination and social exclusion with suffering, experiencing negative feelings such as sadness and anger. Given the frequency with which obesity-related discrimination has been taking place in the general population, it is not surprising that experiences of "being avoided, excluded, or ignored" occur (27) . The negative judgment by the obese body society generates feelings of shame and the reduction of the desire to relate to other individuals, to go out, to have sex and, finally, to social isolation (28)(29)(30)(31) .
The relationship between obesity and derogatory moral values is a sociocultural problem already documented in the literature, as well as society's widespread belief that body weight is under an individual's personal control (6) . Today, where the beauty of thin bodies prevails, mainly highlighted by the media, there is the emergence of a lipophobic society, which at the same time establishes an environment that encourages and promotes obesity, while condemning it, becoming oppressive. and generating psychic suffering (29) .
Feeling ridiculed upon entering a store and trying to buy a costume, in addition to the difficulty of finding their number, were discriminatory experiences (30)(31) . They demonstrated the unpreparedness of attendants to deal with differences, as well as the fashion industry's callousness in not making appropriate clothing available for all body types. It helped to make obese people not look pretty and need to disguise their fat. Stigma is considered a social construction whose objective is to expose the inferiority of individuals (8) .
Our study showed that participants living with obesity are exposed to a wide range of experiences of discrimination with negative feelings having a profound impact on their psychological well-being. Reference to the feeling of sadness, shame, fear, anger, frustration, recurrent low esteem and discouragement in speech, and sometimes even crying during the interview, reaffirms the relationship between discrimination and suffering. Experience of discrimination is significantly associated with low self-esteem, shame, isolation, antisocial behavior, different stress levels to adult depression (7,31) . Data from a systematic review show that discrimination-induced social exclusion results in increased shame in obese individuals, leading to the conclusion that this feeling seems to play a crucial role in these people (27) and may determine attitudes to hide their body fat.
Some women, particularly those who have given up trying another job selection, may have had their economic lives damaged, with less opportunity for financial gain or even career advancement, further increasing social inequality. In the workplace, discrimination can create serious problems and have disastrous consequences for skill performance security, the interpersonal relationships needed in that environment, and even insecurity to look for other opportunities (19) .
Although obesity is a complex disease of multiple causes and results from people responding normally to the obesogenic environments in which they live, society attributes the responsibility for overweight to individuals, and associates them with laziness and other negative attributes (29) . Guilt can aggravate emotional discomfort, cause fragility and vulnerability that does not allow it to resist, with the acceptance of internalized negativity the feeling of deserving stigma and discrimination (32)(33) .
Some testimonials revealed that the participants did not feel able to face the situation, choosing to suffer in silence, flee and give up the possibility of being respected (34) . When an individual experiences a risk of stigma, they may experience a high level of stress, have difficulty communicating effectively, coping with the problem, adapting or even overcoming it (35) . The way in which we respond or face the problem relates to life experiences and personality. Faced with embarrassing situations, some are fragile, distressed and insecure, while others develop emotional and behavioral coping strategies through shifting focus and protective behavior (36) .
Although there is already a vast literature on manifestations of discrimination related to overweight, there has been little attention to the formulation and therapeutic interventions with individuals who experience and internalize this problem. Negative influences of overweight discrimination are preventable. The first step in prevention is to alert the public to the importance of the issue by emphasizing that teasing or stigmatizing overweight individuals does not encourage them to lose weight and can lead to health problems.
Women with introjected stigma need special attention and should be referred for psychological support interventions. Interventions aimed at reducing discrimination due to obesity should be carried out not only with victims and health professionals, but should reach schools, human resources professionals and society in general. Health professionals, who work in Primary Care and referral centers, should not ignore the situations of discrimination that generate suffering experienced by these people, and should include sensitive and expanded listening in their practices to help them cope.

Study limitations
We emphasize that the analyzes may be limited by representing perceptions of a particular group, considering that the research was conducted with a local population, in a single reality, with practically the same social characteristics. Although generalizations of the results cannot be made, they reveal the need to broaden the approach of people with obesity beyond the problems related to the physical-biological sphere.

Contributions to nursing
The data found in this study revealed that stigma and discrimination by overweight are widespread in our society and cause suffering. Thus, they serve as a reference point for further reflection on this theme, for proposing social interventions that minimize this problem. The data provide support for directing care practices that ensure the quality of interpersonal relationships between overweight women and health professionals.

FINAL CONSIDERATIONS
The three categories emerging from the analysis of the present study evidenced the presence of stigma and the experience of discrimination by overweight women in daily life activities. Participants experienced different situations of discrimination in different social contexts, which caused suffering, embarrassment, feelings of inferiority, sadness, shame, fear, anger, frustration, low esteem, discouragement, and illness. The stigma perceived and internalized by women brought serious psychosocial repercussions such as behaviors and attitudes of social isolation, deprivation of marital intimacy, removal from work, concealment of the body, illness among others. The study reinforces that stigmatization and discrimination are frequent processes of devaluation of women that cause deep suffering and nullify their potential. It is extremely relevant the integrated action of health professionals with a sensitive eye and beyond the clinical problems brought by obesity, providing beyond the reach of the goal of weight loss and metabolic control the welcoming and strengthening of women for better social coping of the condition. that threatens and makes her suffer.
The results of this study are expected to encourage the development of new research, especially in the area of nursing, whose scientific production is incipient about the work of nurses directed at people with obesity, including psychosocial factors in the process of falling ill and taking care of themselves. It is necessary to expand research to other social contexts, including in the agenda of academic discussions and training programs of health professionals the creation and strengthening of strategies and interventions to combat the stigma designed and internalized by overweight women.