Dear trans friend who was just denied gender affirming surgery because your BMI was “too high,”
I’m sorry for the ways the systems continue to fail you.
I’m so sorry that the messages around your body and your autonomy over it are continuously challenged, invalidated, and guarded by other people. It’s so unfair. It’s so unjust. I see your pain, your confusion, your rage, your distrust.
Our medical systems are built on oppression, just as many (all?) of our cultural “norms.” This means that there will be clinicians and surgeons who don’t understand that the BMI system was created in the 1800’s and hasn’t been updated. That BMI was never intended to be used on an individual basis (just groups, for research), and that the ranges have been skewed “to be easier to remember.” That being “overweight” or “obese” are stigmatizing words that aren’t behaviors or choices or something to be diagnosed. That the World Professional Association for Transgender Health (WPATH) doesn’t even specify BMI requirements for gender affirming surgery.
That surgical outcomes are indeed not worse for folks in larger bodies, backed by more and more research. That promoting weight loss is promoting eating disorders. That mentioning weight loss can be incredibly triggering for those recovering from an eating disorder. That weight loss and/or engaging in eating disorder behaviors before surgery can impact wound healing and infection rates. That engaging in weight loss behaviors doesn’t even come with a guarantee of weight loss, and that weight cycling increases the risk of other harmful effects in our bodies. That ignorance of humanity has a direct impact on folks mental and emotional well being, i.e. their health (which doctors are apparently *so* worried about to begin with). That a big reason some surgeons aren’t operating on larger bodies is because of their own egos around what looks “good” in post-surgical healing and the photos on their websites.
IN RAGE WITH YOU.
And yet, I feel conflicted in how to best support you. As a clinician who works from a weight neutral lens, I am enraged with the emphasis on weight and BMI in our medical system, trans healthcare, and gatekeeping. There is no safe, sure way for anyone to lose weight, which means I cannot ethically encourage or recommend weight loss as an option. And that breaks my heart to feel like another thing standing in your way of feeling affirmed in your identity.
So I’ll keep holding space for the knowing that there’s nothing wrong with you and everything wrong with the system, friend. I’ll keep showing up with acceptance that there are no easy answers and that all of the options might suck. I’ll get creative alongside you in finding other options, finding new funds, creating new opportuniites, and leaning on community. I’ll keep working and hoping for a better future; one that has you in it in all your magic + glory.
If you’re reading this, I hope you know that you are deserving and cherished. If our paths ever cross, I promise to do my best to serve you. And if our paths never cross, know that I’m fighting for you.
*hey Alexa, play The Village*
In rage, in solidarity,
Charlie*
Research associated with weight bias/BMI gatekeeping/actual outcomes for folks in larger bodies post-op (some problematic language):
Low Albumin Levels, More Than Morbid Obesity, Are Associated With Complications After TKA
Body Mass Index Requirements for Gender-Affirming Surgeries Are Not Empirically Based
What’s Wrong With the ‘War on Obesity?’ A Narrative Review of the Weight-Centered Health Paradigm and Development of the 3C Framework to Build Critical Competency for a Paradigm Shift
Surgical Site Infections in Genital Reconstruction Surgery for Gender Reassignment, Detroit: 1984–2008
Additional related resources:
Body Mass Index Requirements for Gender-Affirming Surgeries Are Not Empirically Based (written by some of our incredible Denver clinicians)
*This post has been updated since I changed my name and has been reflected accordingly
Send me a message to stay in touch. Want to learn more about what it’s like to work with a queer dietitian who specializes in eating disorders? Email me to chat about supervision!