EBB 234 – Tackling Fatphobia in Lactation with Kristin Cavuto

• EBB 99 – Plus Size Pregnancy and Birth with Jen McLellan 
• Harvard Implicit Bias Test
• Fat Phobia Scale Revisited by Robinson, Bacon, et al. 
• HAES (Health at Every Size) 
• The Body is Not An Apology 
• National Association for the Advancement of Fat People
• To follow Kristin: https://www.facebook.com/SmartMamaNewJerseyIBCLC
• Kristin’s current project: https://www.everybabyeats.com

Rebecca Dekker:

Hi everyone. On today’s podcast we’re going to talk with licensed clinical social worker in IBCLC, Kristin Cavuto, about the importance of advocating against fatphobia in lactation.

Welcome to Evidence Based Birth® Podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Hi everyone. My name is Rebecca Dekker, pronouns she/her and I will be your host for today’s episode. Today, I’m so excited to welcome licensed clinical social worker and IBCLC, Kristin Cavuto. Before we interview Kristin, I want to let you know that we will talk about the intersection of fatphobia and racism.

If there are any other detailed content or trigger warnings, we’ll post them in the description or show notes that go along with this episode. And now I’d like to introduce our honored guest.

Kristin Cavuto, pronouns she/they is a licensed clinical social worker in IBCLC and private practice in central New Jersey. Her practice specialties are low supply, parental and infant mental health and the intersection of ethnicity, sexual orientation and gender in the care of the new family.

Kristin has spoken on various lactation, mental health and equity topics for USLCA, GOLD, the Lehigh Valley Breastfeeding Association Conference, the Appalachian Breastfeeding Conference, Annie Frisbie Learn, Queering Mental Health and many others.

Kristin designed and taught a training course on Mental Health First Aid for perinatal providers. They have also been a featured speaker on several lactation related podcasts and serve as a legal advocate and expert witness for cases involving lactation and child welfare.

Kristin is the mother of two children who nursed full-time despite maternal IGT and who are now 16 and 13. Kristin is also an anti-racist activist and an LGBT+ activist, a member of Transformative Works fandoms and makes fighting for a better world part of their daily life. We are so thrilled that Kristin is here. Welcome to the Evidence Based Birth® Podcast.

Kristin Cavuto:

Thank you so much for having me. I’m glad to be here.

Rebecca Dekker:

Kristin, I would love to hear your journey in becoming a lactation consultant because you do so much work. And how did you even get involved in this field to begin with?

Kristin Cavuto:

Okay. So I sort of say that I’m like one of those kids that had cancer and then became an oncologist. I was minding my business and had a perfectly lovely career as a therapist mostly working in addictions. I worked at rehabs, having a great time and then I had my first child.

And at six weeks old, we had seen five or six IBCLCs. He was under birth weight. He was starving. He had red brick dust diapers, and none of them had even done a weight feed. It took to the sixth person for them to tell me that in a half hour of nursing, he had transferred a quarter ounce.       

And that was what was wrong. And so I basically had to find out that I had IGT. I did a ton of research and found a tiny little reference in one paragraph of a book and brought that to my doctor to get it confirmed.

Rebecca Dekker:

And what is IGT because we mentioned it in your bio?

Kristin Cavuto:

Sure. And I don’t love the term, it’s called insufficient glandular tissue or hypoplastic breast. It just means that through whatever reason, there’s lots of reasons. It’s something I talk about a lot. It can happen prenatally.        

It can happen at puberty or in other parts in life. You just don’t develop the milk making tissue in your chest in order to make enough milk, so there’s something anatomically different about your breast.

Rebecca Dekker:

So what happened next when you finally realized that was the problem?

Kristin Cavuto:

Well, I ended using a supplemental nursing system and donor milk and taking, I think at one point up to 48 pills a day between prescription and herbal galactagogues. And he ended up nursing until he was almost six years old. So it ended up working out and then his little brother was born.      

And we went through the same journey, but he didn’t have to starve because we knew about it from the beginning. We were able to have donor milk on board and the right medications on board right away. It was basically, I got into volunteer lactation work pretty soon after that.       

And then after a few years of doing volunteer work, it occurred to me that I was really enjoying it and I was using a lot of my counseling skills that I learned as a therapist. So I went back to school and became an IBCLC. And I’ve been doing both jobs ever since. And I really love it.

Rebecca Dekker:

I want to go back to, you mentioned, in your journey you used donor milk. How did you go about getting donor milk? Was it through informal or formal channels?

Kristin Cavuto:

So with my first, he was born in 2005. And at the time, I didn’t even know that informal donation was a thing. It wasn’t something that was talked about. The internet was available, but it was live journal. There was no really other social media. So we bought milk from a milk bank.   

We were very privileged to be able to do it. It was very, very expensive. It was pretty hard. By the time my second came around three years later, I knew about informally donated milk and that’s what we did. I had probably five or six different donors.         

But with my second, because I was using prescription medication and because with every baby you make a little bit more milk making tissue throughout the pregnancy, I did have a slightly larger supply with my second. And we only needed to use the donor milk for a few months with them.

Rebecca Dekker:

And with your first baby, what percentage of the milk were you making and your baby was eating versus the donor milk?

Kristin Cavuto:

So before I went on domperidone, I was making about four to five ounces in 24 hours. So he needed another 20 to 25 ounces of donor milk. Once I was able to get the medication straightened out, I was making about 20 ounces a day and he needed another five to 10 donor milk.

Rebecca Dekker:

So when you went back to school to become an IBCLC, what kind of path did you take? Because I know there’s different paths and I always love hearing that story.

Kristin Cavuto:

I was a pathway one, and I say that with a little bit of shame because I do think that it’s not the most well prepared pathway. I don’t think I was a very well prepared IBCLC. I have certainly learned a ton in the past 12 years of working. Because I was already a volunteer breastfeeding counselor, so I had my hours already, I just needed them to do the lactation related classes.   

And I had already had most of the college level classes because I already had a master’s in social work. So I just needed to take a few other ones. So for me, really, it was mostly the lactation specific education I needed to do and then taking the exam.       

If I was doing it now, if I could go back now, I would definitely do pathway three. I think that the people I know who are pathway three’s, that means people who are using a mentorship approach, who are actually working with another IBCLC and being taught hands on as well as taking the classes.         

I think that they start out as better IBCLCs. When I became an IBCLC, I had never even met another IBCLC. I had never worked with one, and that’s allowed. So yeah, it’s a good thing that I spent the next 12 years working really hard to learn because I certainly wasn’t prepared by my education.

Rebecca Dekker:

And who knew that it could take so many years to learn everything there is to know about breastfeeding or chestfeeding and human milk.

Kristin Cavuto:

Under no circumstances do I know everything there is to know. I really truly believe in collaboration. And my colleagues are some of the smartest people in the entire world. I learn from them every single day.

Rebecca Dekker:

That sounds like an incredible field to be in. Can you talk, I know you wanted to share with our audience about fatphobia, and before we get into fatphobia in lactation, can you just tell us what terms you prefer to use when talking about this subject?

Kristin Cavuto:

Sure. So I’m going to be using the word fat as a neutral descriptor. And it’s really important for me to talk about that at the beginning, because a lot of people will get really upset about hearing me say fat people, fat clients, fat practitioners.  

I use it the same way I would say blonde or tall. It’s just a way of describing a body. Unlike the words overweight or obese, it’s not a medicalized term. It does not automatically assume pathology or dysfunction. It’s just a body descriptor, but it’s one that matters.    

It’s one that matters because we’re treated differently in society and we have some structural oppression going on, but it’s important for everyone to know, I think it’s fine if you want to use cutesy terms.      

Some people say plus size, some people say fluffy, that’s all very fun and that’s fine and it’s not going to hurt anyone. I just say fat. I would encourage anyone who feels concerned when they hear the word fat to look at their own fatphobia, whether it’s internalized fatphobia or fatphobia for someone who’s not fat.        

Because if you hear the word fat and automatically assume it’s bad, take a moment and think about why. Do you think tall is bad, short, blonde, brunette? Those are other body descriptors.

Rebecca Dekker:

I think that makes sense. And we had, Jen McLellan, the founder of Plus Mommy on a podcast episode and she talked about the importance of using the terminology that people themselves feel comfortable with.    

When you’re an ally, when you’re working with people who are fat or any, you reflect back the words that they use about themselves. I thought that was good advice.

Kristin Cavuto:

I will say, when I’m working with clients, I certainly try to always use the words they use for themselves, but I won’t use the word overweight or obese with somebody who is also fat, because I’m not going to put a oppressive word on them.

Even if they’re using it for themselves, I’m going to model something better. So if they’re not ready to hear the word fat, I’ll say plus size, and that’s another fairly neutral term. I mean, it’s still sort of indicating that there’s a standard size that it’s plus of, but it’s certainly less medicalized and less pathologizing than to say obese.

Rebecca Dekker:

So can you talk with me about, and our audience, about what is fatphobia and how does it show up in birth and lactation?

Kristin Cavuto:

Sure. So I mean, first let’s talk just a little bit about fatphobia in general because it shows up in every area of our society. It’s just like any other form of oppression. And of course, all oppressions are intersectional. So people are going to experience them differently depending on what other identities they have.    

So like we all have privileged identities and we all have marginalized identities, every single one of us. For instance, I have white privilege, but I’m a fat person. So my fatness and my whiteness intersect at a different place than somebody who is black and fat, or somebody who is black and thin.

They’re all just different intersections of privilege and marginalization. So it’s important that we sort of remember this as a complex issue. But fat people experience workplace discrimination, discrimination in the legal system, discrimination in public spaces and absolutely discrimination in healthcare, which is mostly what we’re going to be talking about.  

But basically, every form of discrimination that you can imagine a person can experience, fat people also experience because of their fatness.

Rebecca Dekker:

I remember one time I was teaching an auditorium full of about 100 nursing students, and they’d already had about a year of clinicals under their belt. And we were talking about fatphobia and I actually taught it as part of my class on physiology.

And I asked the students in the room to raise their hand if they’d heard healthcare workers at the hospital across the street, belonging to our university, if they’d heard healthcare workers making disparaging or discriminating comments about a patient size and every single student raised their hand. So it’s being modeled to them as early as nursing school.

Kristin Cavuto:

Yeah. I mean, we know about 25% of nurses admit to being repulsed by their fat patient. About half of physicians think that fat patients are non-compliant just by nature. They often refuse to treat pain in fat people.

Very similarly, how people refuse to treat pain in women versus men, they refuse to treat pain in black bodies versus white bodies. So it’s people who are considered less than human, their pain isn’t treated and fat people are one of those groups.

Rebecca Dekker:

So, moving on from general fatphobia and oppression of fat people, we mentioned healthcare. And then moving on to pregnancy and birth, where do we see that?

Kristin Cavuto:

So fat people have a hugely high rate of unnecessary intervention. 71% of fat people have cesarean sections despite the evidence showing that only very few fat people need them at higher rates than thin people. 71%, that’s a huge number.      

I mean, we already know that everyone has incredibly high rates of unnecessary c-sections, I know you guys talk about that a lot, but 71%. Okay. They have double the rate of inductions, with the reason being provider attitude as the reason for the inductions.   

So unnecessary induction to support leads to most of those sections. For instance, only about half of people with gestational diabetes are fat, but many fat clients are forced to take that glucose tolerance test monthly during pregnancy. That’s really common.

I mean, can you imagine having to drink that horrible stuff every single month? And then every single month, basically we wait for your results to be told if you are going to be further medicalized in your pregnancy, further risked out of low risk birth. Fat clients actually have a 20% lower rate of pre-term birth than thin people do.

So, fatness is actually protective of pre-term birth, but they have a significantly higher rate of provider indicated pre-term birth. Meaning that providers are doing inductions and C-sections early for non-medical reasons causing pre-term birth, even though fatness is protective of pre-term birth. About 15% of OB practices, won’t accept fat clients at all.

And what that means is that in a lot of areas of the country where we know there are medical deserts, where there are places where there are only one or two OB practices, especially if somebody’s on Medicaid, it’s quite possible that someone could find themselves not being able to find a provider that will take them on.

That happens really frequently. Many, many midwife groups, whether they want to or not a lot of them have their hands tied by law, are not allowed to accept a healthy fat person into their practice because just the fact they’re fat is pathologized and considered disease in and of itself, even in the absence of any actual disease. Yeah.  

So, there’s also pressure to be sterilized during labor. I’m sure that sounds familiar when we’re talking about other marginalized groups, fat people are often pressured to be sterilized. And in terms of lactation, they’re often told that they can’t breastfeed.

I’ve even had to do some call outs within the lactation field of educators who were teaching in lactation classes that fat people aren’t going to get their milk in on time. Fat people are going to need to supplement. Fat people are going to automatically have difficulties with milk supply.

Rebecca Dekker:

And why do you think they have those assumptions about milk supply?

Kristin Cavuto:

So, what’s interesting is we have a body of literature that tells them that, but that remember, as we always talk about, we look for evidence-based, but we need to understand that the evidence is often biased itself. We need to separate the concepts of fatness and metabolic disease. Okay.

So, someone who has metabolic disease like insulin resistance, which goes along with PCOS, which goes along with gestational diabetes and type 2 diabetes. People with metabolic disease do have delayed lactogenesis too.

They do have often lower milk supply and more difficulty bringing in milk, but fatness does not correlate with metabolic disease. Some fat people have metabolic disease, but some thin people have metabolic disease.

Rebecca Dekker:

I can think of several friends just off the top of my mind who have metabolic disease who are thin.

Kristin Cavuto:

Absolutely. And many, many, many fat people don’t have metabolic disease. They have perfect blood pressure. They have perfect blood sugar. They don’t have insulin resistance. Everything’s gorgeous, but they’re assumed to have metabolic disease just because they’re fat.

And so, what we have in the literature is this conflation of fatness with disease. And therefore what they’re looking at in these studies are people with metabolic disease and they’re conflating it with fatness.   

And so, we have a whole literature that’s teaching us that fat people don’t make good milk. They don’t make enough milk and they have delayed lactogenesis too. So they need to supplement. And it sets fat people up for that spiral of early supplementation leading to cessation of breastfeeding.

Rebecca Dekker:

I know you’ve studied a lot on the intersection of fatphobia and racism. Can you talk a little bit about how fatphobia is connected to the history of racism in the United States?

Kristin Cavuto:

Sure. I mean, what I really want to go to with that is we’ll talk a little bit just about, I call it the war on obesity because it originally and always has been and incredibly racist war, an incredibly sexist war as well. So if we go back just about 100 years ago, before the 1920 or so, there wasn’t a whole lot of in the literature correlation between fatness and ill health.

There really wasn’t a lot talking about that. Some people were fat, some people were thin. We didn’t think about it too much. What happened in the 1920s, and originally this was super racist right from the beginning, life insurance companies, so not medical providers, life insurance companies began to use weight charts as a metric for insurability.  

And what they did, of course, was look at people who lived the longest and calculated their weights and said, well, people who were these weights lived this long, but who are the people who have long lives?   

People who are white, people who are middle class or upper class, people who have access to healthcare and often people who are men, especially in the 1920s before there was access to birth control, people who weren’t having 10 or 15 babies. Right? So from the very beginning, the idea of fatness and disease was automatically racist.

It was automatically assuming that the white male body was the standard to compare everything from. And that continued all the way through in the 1970s, they started using the idea of BMI. That’s what we talk about a lot now. We hear people talk about what is your BMI? And your BMI, what category is it in?

Well, the BMI was meant as a research problem to look at populations. It was never meant to be looking at individuals. In fact, it was used to study white European men in groups. So it was a research study to look at white European men. It was never meant to look at anyone else. It was created just for them.

And it was created to look at huge populations and compare them, not individuals, but however, by the ’80s, doctors started using it to look at individuals. So again, we have women, we have people of color. We have people from every different ethnic group being compared to the standard of white men and found different.

Surprisingly enough, maybe a little bit different, but in that comparison, they were decided as different was bad. There’s never been a moment in this war on obesity where it hasn’t been steeped, absolute racism and sexism. I mean, like everything else in this country, right?

Rebecca Dekker:

I’ve known about the intersection with racism and fatphobia and oppression of fat people, but I hadn’t thought as much about how fat women are judged by society and by doctors, just in general, astronomically more than fat white men.

Kristin Cavuto:

In general, I mean, we know that for instance in the legal system, and this is for women in particular, men don’t seem to have this problem. Women, both black and white in this particular case, fat women are giving longer sentences for the same crimes than thin women are.

Now we also know, of course, that black people are given much longer sentences for the same crimes than white people are… So can you imagine when you have both of those oppression? So we see fat black women going to prison for years longer than a thin white man being convicted of the same crime.  

And of course, the conviction rates are higher. The same thing goes in the workplace, we see people not being hired, not being promoted because of their fatness, the same thing for their blackness. So someone who’s dealing with both of those oppressions is dealing with a lot.

Rebecca Dekker:

Now that we’ve kind of covered what fatphobia is and how it’s been developing over the last 100 years, I was thinking back to your story when you were sharing your difficulty in getting help with lactation, nobody recognizing the problem for six weeks. Can you talk a little bit about your experience when faced with fatphobia during pregnancy and lactation?

Kristin Cavuto:

Sure. So I’ve had some interesting personal fatphobia experiences. I will say first that I’m very privileged in terms of economic privilege, white privilege and educational privilege. And those things have definitely helped me in many, many ways to avoid the worst aspects of fatphobia in some medicalized situations.

People who can speak the language of medical and who look like people want them to look, skin tone wise, certainly get treated better, but I’ve had some interesting experiences. One of the ones that I always talk about is one, not during pregnancy. I went to an urgent care clinic for a sprained ankle. This is just maybe five years ago.   

And it was for a sprained ankle. I walked in, I just wanted to get an X-ray to make sure it wasn’t broken. And the doctor sat me down and said, “So do you have children?” “Sure. Okay. Yes, yes. I have two children.” And he said, “Really?” I said, “Yeah, yeah. I have two boys.” He goes, “How old are they?”

And then I told him, and he was like, but gee, he’s like, “Can you show me pictures? Do you really have children?” And I was like, “What?” And he was like, “Because fat people don’t usually get their periods, and I don’t really expect that you actually. Do you actually have children?” He really was asking me and questioning me and I’m like, “First of all, yes. Second of all, I’m here for my sprained ankle.”

He’s like, “Well, you must have PCOS.” He’s like, “Did you have to use IVF to have your children? That must have been it. You must have had fertility treatments to have your children.” And this went on for a good 10 minutes until I finally had to get very sharp with him and say like, “Look at my ankle you jerk.”  

But yeah, that was one of the bizarre experiences. I mean, can you imagine how I would’ve felt if I hadn’t done years of therapy and feeling okay about my body, that could have sent me to all sorts of places, but one of the dangerous experiences I’ve had. So that one was just like bizarre and upsetting. The dangerous one I had was one time I was at my doctor’s office and was being seen by someone who wasn’t my regular doctor.

And they took my blood pressure with a skinny person cuff. And I said to them, “That’s not going to work for me. You need to go find the fat person cuff. I’ll wait. Go find it please, because that one’s not going to work.”

And they insisted, and I said, “Okay, well, you can take it on my forearm then because that’s another option that will work pretty well.” They refused. And so they took it and of course it was dramatically high and I don’t have high blood pressure. I’ve always had in fact, pretty low blood pressure.

And immediately this person got out their prescription pad and wrote me a prescription for blood pressure medication and said, “You must have chronic hypertension. Please go take this medication. Start it immediately because if not, you’ll look like a stroke waiting to happen.”

And I said, “I don’t have high blood pressure. Please go find the correct cuff and take my blood pressure again.” And it took me, again, about 10 minutes of arguing this person. And finally I said, “Okay, I want it put into my chart that you refused to use the correct size cuff on me. And that you’re basing a medication recommendation on this inaccurate blood pressure.” So finally he went and got it.

My blood pressure was 115 over 65. So what I want to say here is imagine if I was someone who did not have a medical background. Okay. Who was not an IBCLC and also the daughter of an RN who was brought up understanding these things. Imagine if I just said, “Oh, that’s my blood pressure. Wow, I guess I have high blood pressure.”

I would’ve taken that prescription, gone home with it. And who knows what that would’ve done to me, who already is on the low side of blood pressure, it could have been very dangerous and that happens all the time. So those are just two super minor examples of a fairly privileged person.

Rebecca Dekker:

Do you feel like your difficulty getting help with lactation, that part of that neglect from the people who assessed you was related to fatphobia?

Kristin Cavuto:

I honestly think at the time it was probably much more related to the general incompetence of the people I was seeing that they really just didn’t understand. See, I mean, some people still say things like almost everyone can make enough milk. 

If you don’t make enough milk, you’re not trying, but we don’t hear that nearly as much as we heard 16, 17 years ago. That was a really common thing that people used to say to lactating people back then, was like, there’s no such thing as low supply. Low supply just means you’re not trying harder

Rebecca Dekker:

Or it’s because you’re supplementing.

Kristin Cavuto:

And so, these people looked at me and they asked me a ton of questions and they said, “Your management is perfect. You’re nursing around the clock. You have a beautiful latch. Look at that baby, nothing wrong with their oral anatomy.” Not that they were checking, but I had this beautiful baby who was a great nurser.   

And they said, “Well, don’t worry about it. Just keep nursing and it’ll happen.” And then a week later, “Just keep nursing. It’ll happen. Look at that great latch.” And I mean, it took until he was starving and the pediatrician was threatening to call child protective services on us.

And there’s another instance of both privilege and oppression that our pediatrician was so concerned with this baby’s weight that she was threatening us with a phone call to child protective services. If I was black, I’m certain she just would’ve called. So there’s an area of privilege absolutely. If I was thin, I’m not sure she would’ve threatened. So who knows.

Rebecca Dekker:

When you were sharing your story, you talked about the feeding weight. For our listeners, especially those who are pregnant for the first time, can you explain what that is and how that can be a tool to determine your milk supply?

Kristin Cavuto:

Sure. So for someone who’s pregnant, especially if you have no history of low supply and you have no medical indicators that you will have low supply, it’s not something that you’re probably going to have to experience. Most people do not need IBCLC care necessarily. They need basic breastfeeding support. And most people don’t need a weight feed.

However, if you find yourself in a situation with a newborn that is not gaining well, and someone tells you, you need to start supplementing this baby because your baby is not gaining well. You absolutely need to reach out to your local IBCLC and have them do a weight feed.   

And all that means is that they weigh the baby on a very special scale that is ridiculously super expensive. So it’s not the kind that you get at Target. It goes down to really, really low weights. They weigh the baby, you nurse the baby, and the baby gets weighed again so that you can tell exactly how much the baby was taking at the breast.

So that then the person could make an analysis and determine if your supply really is lower or if the baby’s taking plenty at the breast. It’s a really simple tool that IBCLCs use and that is super indicated in the situation where a baby’s not gaining well.

Rebecca Dekker:

It seems like it would be really helpful to give you some concrete info about what’s happening at that moment.

Kristin Cavuto:

It’s really satisfying, honestly. I mean, I use them with every client I see, because I see a lot of low supply clients one, but two, because even for the people who are feeling good about nursing and nursing is going fairly well, it makes them feel really reassured to have concrete evidence.

Your baby just took a three-ounce feed. Your baby just took a three and a half ounce feed, you’re doing fine. And it can be very reassuring in a culture that’s a very bottle feeding culture where we’re sort of brought up to expect to be able to see ounces on the side of bottles. And then we realize our boobs don’t have ounce markers, it can be very nerve-wracking.

Rebecca Dekker:

I love that we don’t have ounce markers on our boob headsets now. That’s awesome.

Kristin Cavuto:

Yeah. And for some people who do have very low supply and are sort of working on it, some people can rent a scale like that and use it at home. I do not recommend that the average person does that because it will drive you insane.  

People will start weighing their baby 15 times a day and then it really will exacerbate anxiety. I don’t recommend that, but it is a possibility for people who need it clinically,

Rebecca Dekker:

What are some ways, Kristin, that people in your field of lactation can address and dismantle fatphobia?

Kristin Cavuto:

Yeah. There’s a lot of ways. So there’s some structural ways and then there’s some clinical ways. Structurally, we need to start questioning the research. We need to start actually reading. A lot of us don’t read the research studies, and myself can be included in that. We’ll read the abstract, we’ll read the blur, but then we won’t really dig into the study.

This research studies are hard. We need to dig into the study and really see what they’re measuring here. So when they talk about obesity, what do they mean by that? Are they just talking about people who happen to have a lot of adipose tissue on their bodies or are they talking about people with metabolic disease? Because those are two different groups.=   

The groups may be overlapping sometimes, but so I think people and people with metabolic disease, those are overlapping groups too. So we need to see really what these research studies are saying. So clinicians need to be reading their studies better, and then they need to be challenging the study.  

Because when the study is clearly looking at people with metabolic disease, we need to be getting in touch with the authors and saying, why are you calling this a problem with obesity? Why aren’t you calling this a problem with people with metabolic disease? That would be the accurate medical terminology here. And it would be less fat phobic. 

So that’s some of the structural things we can do. Clinically, we need to root out our own fatphobia before we start working with fat clients, because there is nothing worse than going to a lactation consultant and being postpartum and super vulnerable.

And everyone is super body conscious you just gave birth. Everything is leaking and bleeding and you feel puffy and weird, no matter what your body size is and to have a lactation. And then you have to take part of your shirt off, you’re kind of half-naked in front of this stranger.

To have them look at your body with judgment and look at your body with potential disgusted is devastating and it will absolutely derail breastfeeding. Some research talks about how fat people have lower breastfeeding initiation rates. And my comment will be well, yeah, that’s the fatphobia, stupid.

They’re not initiating breastfeeding because it requires taking your breast out. And in the early days it often requires 27 hands and being naked, right, in those first week or so. And people don’t want to expose their bodies to a fat phobic world, especially when they’ve been trained to hate their bodies.  

So yeah, of course, we as lactation consultants need to do better. We need to do better at making sure our fat clients feel welcomed. We need to make sure the furniture in our office is big enough for our fat clients. We need not to make sure we actually have chairs that will hold them.

I’ve been in lactation consultant offices that just have a little glider chair that is I’m well past the weight limit for. And that’s just as a guest hanging out with them. Imagine how I’d feel if I was actually their clients, it really sucks.

I can speak for myself, it sucks to walk into a medical provider’s place, and they don’t have a gown that fits you, they don’t have a chair that fits you. The physical office is not made for your body. It’s incredibly unwelcoming. And it tells you immediately that you’re not welcome there.

Rebecca Dekker:

When you talked about addressing your own fatphobia as a clinician or somebody who’s working in the field of healthcare, what are some ways people can determine what feelings and beliefs they have about fat people?

Kristin Cavuto:

Yeah. So let’s just talk about sort of thin privilege for a minute. And I would hope that everyone has talked about the idea of white privilege of male privilege. The unearned benefits that we get from being part of a privilege identity.

So thin privilege, thin privilege means that you can lose your suitcase on a trip and know that you can go into any store and that there will be clothes that you can replace your clothes with. Thin privilege means that you can go to the doctor and whatever your medical problem is you know you won’t be treated poorly because of your body size.

Thin privilege is being able to go on an airplane and not be told you need to buy two seats or not be literally heckled off the plane. It’s being able to go to Target and walk between aisles without bumping into the aisles because the aisles were not made for your body. It’s as simple as that.

It’s being able to go to pay a lot of money to get into an amusement park and realize you can’t go on a single ride with your kids, which is heartbreaking in a lot of ways. It’s a lot of things. It’s a lot of things that are very serious like the stuff about the legal system and about the medical system.

And it’s a lot of everyday little stuff like being heckled in public, being street harassed, which happens to me all the time and I am a middle-class white lady. And living my middle class white lady life, and still have street harassment constantly. Even now that I’m past the age of getting a lot of gender harassment, I get fat harassment now. 

It doesn’t stop. So just understanding. So when I always talk about oppression, I always tell people from privileged groups, our job is to listen to oppressed people and then believe them, even if that’s hard for you to believe because it hasn’t been your experience.

So, I would ask all the thin people who are listening to this, or even average size people, you would say, “Well, I’m not thin,” because everyone in the United States who’s over size 12 thinks that they’re fat. If you can buy clothes in any store you walk into, I’m not talking about you in this, okay. 

I’m not talking about us fat. I’m talking about you, and I talk to you right now. If you’re a thin person, recognize the privileges that you have. Recognize that fat people are having a different life experience than you’re having and it’s because of structural oppression. And believe them when they tell you it.  

Believe them. That’s what I say about anyone, listen and believe. That’s what the job of thin people in birth and in breastfeeding should be doing for their fat clients and also their fat colleagues. Listen to them and believe them. And that is a great way to start.

Rebecca Dekker:

It reminds me of, Ihotu Ali, one of our research editors at EEB. Talks a lot about the cross race empathy gap in terms of white healthcare providers not having the same empathy for a black patient as they would for a white patient and they don’t even realize that that’s the case.

And it makes me wonder if there’s research on across body size empathy gap, where you talked about kind of a wide range of fat phobic and oppressive actions ranging from mild all the way to harassment. But I bet a lot of healthcare providers don’t see themselves as being harassment or fat phobic, but if they could kind of take their blinders off and see, they would realize that they have less sympathy for fat people.

And that seems to be a big part of the problem. They don’t come to their fat patient with the same compassion and treat them with the same dignity as a thin body-

Kristin Cavuto:

Because they think they’re less than human, and that’s really what it comes down to. I encourage anyone, I mean, if you haven’t heard of the Harvard implicit bias test, we can give everyone that link. I encourage everyone to go take them. They are just some really cool tests that you can take either on a laptop or on your phone.

They have them now, and they have them for everything. They have them for black versus white. They have them fat versus thin. They have them for colorism within the black community, which is super interesting. They have a ton of them. There’s probably 15 or 20 different tests that show you a picture of your own implicit bias, bias that is unconscious.   

And they’re really cool tests. When I teach classes about medical fatphobia, I always have, as pre-homework, everyone, all the healthcare providers take the fat thin Harvard implicit bias test. And a lot of them are shocked by their level of bias.

They’re shocked. They didn’t realize they were biased. And what’s sad is that, of course, a lot of the fat ones are shocked that they’re biased, that they have so much internalized depression going on, which is really sad and really hard.

Rebecca Dekker:

Yeah. And you can get to that at implicit.harvard.edu, or you can just Google the Harvard bias test. And then another scale that I took at a conference one time, a midwifery conference that was introduced to the Fatphobia Scale by Robinson and Bacon, et al.

And it’s a really simple 14-item questionnaire that kind of assesses your beliefs and feelings towards people who are fat. And it’s super fascinating to take that test and get your score and find out where you fall. Very eye opening.

Kristin Cavuto:

Yeah. And I just want to talk for a minute about another intersection here and that’s with ableism. And that fatphobia ableism have a very strong intersection, because what you’ll hear from people when they’re called out on their fatphobia is they’ll say, “Well, I’m just worried about your health.”

And of course, I can give you research study after research study that actually shows that being fat is not an indication of unhealth in any way, shape or form, but that’s beside the point for a minute. Let’s put that over to the side and say this, even if somebody was unhealthy, does that make them less human or less worthy of good treatment?

And of course, disabled people will tell you, “Yeah, it does seem to be the way that people treat you when you’re disabled.” So that’s another really important intersection is that even if somebody isn’t healthy, shouldn’t they still be treated with dignity in healthcare?

Shouldn’t they still be treated with all of the compassion and all of the pain management and all of the good medical diagnoses that a healthy person would be treated?

Rebecca Dekker:

Yeah. I love that advice. Kristin, do you have any other resources that you would suggest that our listeners check out related to fatphobia?

Kristin Cavuto:

Sure. We have some links that I can share with you. One of them is about HAES, which is Health at Every Size. And Health at Every Size is a really cool thing that all medical providers should know about. It takes the focus of health promotion completely away from body size and puts it on actually health promoting behaviors.

So that’s a really cool resource. Another one is the National Association for the Advancement of Fat People. And that’s a fat liberation straight out, I’m going to erase that part, a straight up fat liberation movement. And that’s different than body positivity because fat liberation is a movement that acknowledges structural oppression and seeks to change it structurally.

There’s also a really cool website called The Body is Not An Apology. And that is one that centers people of color and bodies and fatness and talks a lot a bit about what we can do about that. So those are three resources that I’d recommend looking at.

Rebecca Dekker:

And what about projects you’re working on right now?

Kristin Cavuto:

Sure. Well, so I have my private practice. I see people from all over the world who have low supply. So I can do that virtually. So anyone who’s dealing with IGT or low supply, I talk to them virtually, that’s a specialty. I have a regular lactation practice. I do the court cases lately.

I’ve been doing advocacy and expert witness work, which is really cool, but my passion project right at this very moment is something called Every Baby Eats. And the website is everybabyeats.com. And that was born from this American formula crisis that we’re going through right now.

And as a lactation provider, wanting to do something that was actually useful rather than just saying just breastfeed as if someone who has an eight-month-old formula fed baby could flip a switch and suddenly their boobs would turn on. Because as we all know, it doesn’t work that way. And I got really sick of hearing people say, “Oh, just breastfeed.”

So, Every Baby Eats has a very clear and simple goal. We take pregnant people and parents of newborns under eight weeks old who want to nurse their babies, and hook them up with free or very low cost prenatal breastfeeding classes and re lactation classes or making more milk classes for newborns.

Because if we can reduce the demand for formula by helping those people who want to breastfeed to do so successfully right from the beginning, we can keep the formula for the older babies who need it.

Rebecca Dekker:

That is incredible. Thank you for sharing that project with us. So that just is at everybabyeats.com. And I love that approach of trying to be part of the solution to the formula crisis. And you mentioned something about being an expert witness.

So can you talk just, in our remaining few minutes, that really piqued my curiosity. What do you mean you serve as an expert witness in court cases? I mean, how could there be a court case about lactation? That sounds really bizarre.

Kristin Cavuto:

Well, so there are some just IBCLCs who do expert witnessing, and that’s not what I’m doing. So I am a licensed clinical social worker and an IBCLC and I have a fellowship in infant mental health. So those things all together lead to me kind of being an ideal person to testify in child welfare in cases of child custody.

So, the unfortunate cases where people are breaking up or getting a divorce with a nursing baby or very young baby or a toddler, I have a good intersection of skills that allows me to testify about what reasonable separation would be, about what reasonable custody schedules might look like and to advocate for the best interests of the baby in that situation.

Rebecca Dekker:

Okay. That is not something that had crossed my mind in terms of lactation and being separated in child custody. So in most cases, does the baby stay with the lactating parent or is that not the case?

Kristin Cavuto:

So, it’s super state by state and certainly it’s not a given anymore, even a little bit, that the lactating parent will retain any sort of custody of even a newborn. A lot of the trend in family court is to do 50/50 from birth.

And that doesn’t work out super well for newborns. Newborns do best with if their parents are broken up, having the non-gestational parent have frequent, even daily short visits, then that’s evidence-based, but that’s not what the courts go to.

And so, the evidence-base is there’s frequent short visits, lots and lots of short visits to have bonding while still maintaining their primary attachment someone who’s usually their gestational parent, not always, but usually.

And then the visits being lengthened slowly, slowly, slowly over the first two years of life. And by two or three years old, we can get to 50/50 custody and have it be perfectly okay for the baby.

Rebecca Dekker:

Okay. It definitely is a relief to know that there’s people like you out there who are helping advocate for babies.

Kristin Cavuto:

I’m trying, but again, it’s an issue of access because not everyone that’s all… People can’t afford expert witnesses and people can’t afford lawyers. And so it’s hard to be someone who works within a system that is inherently oppressive. And I try to do the best I can, but I acknowledge that there’s nothing equal about the legal system. There’s nothing equal about what I’m doing as an expert witness.

Rebecca Dekker:

Is there anything else you want to share before we go, obviously?

Kristin Cavuto:

Sure. I just want to talk a little bit about how to provide weight neutral care and advocacy. So basically, we talk a lot about what people are doing wrong. I want us to end it by talking a little bit about what providers can do right.

So, for those of you who are pregnant or who have babies, this is what your provider should be doing for you. And for those of you who are providers, this is what you should be doing. So first, don’t bring up size or weight if it’s not directly relevant to the problem you’re talking about.

That’s most of the time. There’s no need to talk about it. I promise you, your fat client knows they’re fat. You don’t need to tell them. The big question I always say is this, what would you tell a client with these same issues who is not fat? Or what would you recommend for a client with these issues who is not fat?

And that is a statement that every fat person should remember to ask their doctor when their doctor starts talking about their possible PCOS when they’re there for a sprained ankle. Because I guarantee you that, that doctor, if I would’ve asked that question, he would’ve said, “Well, I’d be taking an X-ray right now rather than quizzing you about your fertility history.”

So, what would you tell a client, or what would you recommend for a client who is not fat? I want all of our providers to be modeling fat acceptance and fat liberation and challenging fatphobia in colleagues, which just like challenging any other kind of bias is really hard sometimes, but we have to do it. We have to do it.   

And also challenging it in the healthcare literature like we’ve talked about and definitely teaching clients the facts about weight, health and weight loss and how dangerous those things can be and the facts. We haven’t had a lot of time today to talk about what all those facts are, but those are things that you can easily look up.  

And I’m sure we can talk about at some point in the future, but not telling your client that if they lose weight, they will suddenly be healthier because it’s not true. That’s not evidence-based information. And a lot of doctors really enjoy saying that, even though it’s not true.

So, in general, we can do better. If you have an OB practice, you can actually start thinking about why am I telling fat people they can’t be my clients? Am I worried about my rates? What’s going on here?

And if you’re a midwife for your practice, if your laws are preventing you from taking a healthy fat person on because they’re considered high risk, just because they’re fat, it’s a time for some serious advocacy to change those laws. And not just say, well, that’s just the way it is and throw your hands up because your fat clients deserve better.

Rebecca Dekker:

Yeah. I’ve talked with some fat parents who thought they would get better care from a midwife, maybe more personalized, more compassionate care, but they still ran up against the same fat oppression and fatphobia with even home birth midwives.

Kristin Cavuto:

Oh, yeah. Yeah.

Rebecca Dekker:

Yeah. So nobody’s immune from their own internalized fatphobia. Kristin, I feel like we’ve learned so much from you today. How can people follow you and your work if they want to learn?

Kristin Cavuto:

Oh, the best way right now is to follow my Facebook page, and I’m sure we can put that in the comments. And yeah, that’s the easiest way to contact me and to get ahold of me. And please do check out everybabyeats.com, share the project.     

We have over 75 breastfeeding educators and IBCLCs ready and willing to teach classes, ready to go for free or low-class classes for pregnant people and people who are immediate postpartum period. And we’re waiting for clients to start rolling in.  

We’ve had some, but we’d love to have some more. We’re ready and waiting for you. And please share the project. We also are doing a GoFundMe to try to get some money to pay those teachers. So if you’d like to donate or share that, we’d be happy to have that as well.

Rebecca Dekker:

So, everybody go check out everybabyeats.com and you can follow Kristin at Smart Mama New Jersey IBCLC on Facebook. Thank you so much again, Kristin, for joining us today.

Kristin Cavuto:

Yay. I’m so glad to be here. Thank you.

Rebecca Dekker:

This podcast episode was brought to you by the book, Babies Are Not Pizzas: They’re Born, Not Delivered. Babies Are Not Pizzas is a memoir that tells the story of how I navigated a broken healthcare system and uncovered how I could still receive evidence-based care.

In this book, you’ll learn about the history of childbirth and midwifery, the evidence on a variety of birth topics and how we can prevent preventable trauma in childbirth. Babies Are Not Pizzas is available on Amazon as a Kindle, paperback, hardcover and Audible book. Get your copy today and make sure to email me after you read it to let me know your thoughts.