Resources to Fight BMI-Based Denials for Gender-Affirming Procedures
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I have a series of articles about how to fight BMI-based surgery denials here, as well as a specific list of resources for fighting denials of joint surgeries here. Gender-affirming surgeries are frequently subjected to these denials, holding healthcare that is necessary for people’s physical and mental health hostage for a weight loss ransom.
While it’s typically my policy not to link to studies that include weight stigma, in this case I’m making an exception so please be aware that most links will go to studies that include weight stigma. In addition to the research coming from a place of weight stigma, the language in some of the studies does not reflect current best practices in inclusive language for trans and nonbinary people. I also want to acknowledge that now or in the future the language that I use here may not reflect best practices, I know I come to this work from a place of cisgender privilege and I’m open to being called in or out on any mistakes I make.
I also want to acknowledge that people may choose, or not choose, many different gender-affirmation procedures, and all of those choices are valid. The focus should be on making sure that people have access to the gender-affirming care that they want, and then respect their choices.
I’ll add to the resources below over time so please feel free to leave a comment or email me if there is a specific procedure that isn’t covered here that you would like me to look into and try to find resources for and/or if there are studies you are aware of that I didn’t include.
Another thing I want to point out is that a lot of research and discussion around these denials takes the position that high BMI is what creates the barrier to care when, in fact, it’s the choice to deny care to people with high BMIs that creates the barrier.
The “justification” for these denials is typically that higher-weight people will have higher rates of surgical complications and/or complications during recovery. I want to point out that, even if that were true (and it may not be,) it doesn’t necessitate denial of care. The idea that if higher-weight people can’t have the same complication rates or surgical outcomes as thinner people, then higher-weight people don’t deserve care at all is more weight stigma than science. (Similarly, many of these studies compare transgender and nonbinary people’s outcomes to cisgender people’s outcomes, I want to be clear that transgender and nonbinary people’s access to surgery should be contingent on a favorable comparison to the outcomes of cisgender people.)
Currently, this could be handled through informed consent and shared decision-making, as well as systemic changes to the ways that surgeons’ “statistics” are used so that they aren’t disincentivized to provide care to higher-weight people. Long-term, there should be significant focus and resources dedicated to improving surgeries and recoveries for higher-weight patients. Sending fat patients away rather than developing the skills to properly care for them is a combination of weight stigma and skills development. There are surgeons who perform these procedures on higher-weight patients, it is possible, denial of care is not actually a reasonable or just solution.
Here are the studies:
Weight Loss Ineffective:
This study looked at transgender and nonbinary people who were told that they needed to lose weight in order to qualify for their surgery. They found that 26% of the patients they observed were “ob*se” at their first surgical consult and 27% were “ob*se” at follow-up. They concluded: “Self-monitored weight management is an unsuccessful strategy for improvement even among individuals who would be predicted to be motivated.”
This is not a surprise, it’s what a century of research has shown. Further, these weight loss recommendations create the risk of exposure to weight cycling which is independently linked to the health issues that get blamed on being higher-weight, increased inflammation, and higher overall mortality.
This study looked at the most common gender-affirming procedures, which they identified as “genital and chest” (I want to point out that if you need to present only one study, this would be the one, most of the other resources here are also contained within this study.)
The quick result is that they found that “literature suggests that the most commonly pursued GAS procedures (genital and chest) can be safely performed on ob*se patients”… Research and clinical practice are hindered by continued reliance on BMI as a requirement for GAS [Gender Affirmation Surgery] candidacy.”
A bit of a deeper dive:
They point out that weight loss recommendations are highly unlikely to be successful and can lead to dangerous weight cycling:
“patients who engage in dieting have been shown to gain significantly more weight than nondieters in the long and short term, contributing to a dangerous pattern of body weight destabilization known as weight cycling. Weight cycling is strongly associated with multiple negative health outcomes, including all-cause mortality, cardiovascular disease, immunosuppression, reduced bone mineral density, and chronic inflammation.”
They also explain that in addition to weight cycling these recommendations increase weight stigma which can increase eating disorder risk which can create barriers to surgery and increase the risk for post-surgical complications:
“Such messages from providers foster and perpetuate weight stigma. This contributes to a positive feedback loop of weight cycling through behavioral, physiological, and emotional stress responses31 and is also associated with increased frequency and severity of disordered eating behaviors (e.g., fasting, vomiting, and binge eating).32 These behaviors independently increase an individual's age-adjusted mortality rate, while associated nutritional deficiencies impede wound healing and increase risk of surgical site infections.33,34 In addition, it is worth noting that GAS procedures could help patients decrease binge eating and other disordered eating behaviors associated with weight gain/cycling by decreasing gender dysphoria, which has been shown to be related to disordered eating behaviors.10,12 Thus, providing as many people as possible access to GAS could help reduce weight cycling among TGNC individuals.”
“TGNC individuals are at higher risk for self-reported disordered eating, depression, anxiety, and other mental health conditions,10,12 prescribing weight loss may precipitate or exacerbate these conditions, potentially preventing such individuals from meeting WPATH mental health requirements for surgery.
Finally, they note that these BMI-based denials can disproportionately impact those seeking gender affirming care when cisgender people seeking the same procedures cosmetically may not be denied.
Penile inversion vaginoplasty
“Several retrospective reviews of patients who underwent penile inversion vaginoplasty found that BMI was not predictive of complications or need for revisions. Although some studies, reflective of single-surgeon experiences, suggest BMI is associated with increased risk of complications, the odds ratio was notably lower than for other identified significant risk predictors. Similar findings have been reported for masculinizing genital procedures. Although the selection of phalloplasty technique is influenced by BMI, complication rates for the approach preferred for patients with BMI >30 kg/m2 are lower than for other accepted techniques.”
“Age, body mass index and hormone replacement therapy are not associated with complications and, thus, they should not dictate the timing of surgery”
“ob*se” patients can safely undergo GAS and BMI alone should not preclude appropriately selected patients from undergoing GAS
Gender Affirming Hysterectomy
BMI was not found to be predictive of complication risk for gender-affirming hysterectomy
Complication Rates and Outcomes After Hysterectomy in Transgender Men
“transgender male status and presence of a major medical comorbidity were not significantly associated with complications”
Gender-Affirming Mastectomy
“Chest masculinization surgery [CMS] remains a safe option for TGNB patients and may be safe to perform in patients with higher BMI. The informed decision-making process between surgeons and their patients should clearly delineate the potential risks associated with higher BMI and the negligible overall incidence of significantly morbid complications.”
“a large retrospective review demonstrated that patients with greater BMI do not have significantly higher odds of complications or revisions, which was consistently shown across all classes of “ob*sity.”
“ob*sity was not significantly associated with complications or revisions after gender-affirming mastectomy”
Augmentation Mammoplasty
“BMI was not found to be predictive for all-cause complications of augmentation mammoplasty”
“The rates of all-cause complications were low in both cohorts… Multivariable regression analysis revealed no statistically significant predictors for all-cause complications.
Transfeminine breast augmentation is a safe procedure that has a similar 30-day complication profile to its cisgender counterpart.”
Summing Up
If your healthcare is being denied based on BMI, please know that there is nothing wrong with your BMI, but there is something deeply wrong with the weight stigma that permeates our healthcare system.
Again, if there are procedures that you would like to see research for, please feel free to add them in the comments or email me.
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More research and resources:
https://haeshealthsheets.com/resources/
*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.
Note I don’t link to everything I discuss in this post because I don’t want to give traffic and clicks to dangerous media.
Thank you! I’m a non-binary trans person not seeking gender affirming procedures. I have many trans friends who have and one thing I have learned from them is that some surgeons are reluctant to do procedures on larger people because they are concerned that the person will be unhappy with their appearance results because it won’t be as close to a thin cisgender or trans. person’s appearance. So their strategy has been to bring in photos of people (like celebrities, trans YouTubers or friends who have given permission) of similar body size who have had the procedure or have a current body that is their goal to show the surgeon what they are hoping to achieve. This can help overcome this kind of no. Also, it’s important to weigh the pros and cons of signing anything that disclaims a surgeon of responsibility if you are unhappy with the outcome to make sure that it is necessary and if so appropriately narrow. Generally, it’s best if it is something advisory such as a statement that the doctor advised the client that outcomes vary, which is more reasonable than a statement that they aren’t liable for complications etc.
thank you for using your platform to elevate this!