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ABSTRACT
The use of BMI to determine eligibility for gender-affirming surgeries, specifically for top surgery, is not based in science. The present work analyzes current policies regarding BMI limits alongside research participants’ experiences with BMI limits when attempting to access gender-affirming surgeries, arguing that BMI use presents a major barrier for fat trans and nonbinary individuals seeking transition-related surgeries. Based on previous literature and research participants’ experiences, this work further argues that BMI limits (and the lack of transparency regarding these limits) are harmful insofar as their use may result in denials or delays for these surgeries, prescriptions for weight loss, and negatively affect the mental health of those seeking surgery. The use of BMI may be grounded more in concern about aesthetic surgical outcomes rather than concern about health. Variation in coverage in Canada for all essential parts of top surgery (specifically the lack of coverage for liposuction and its classification as cosmetic in some provinces) present economic barriers that affect fat individuals more than those who are thin or average.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Correction Statement
This article has been corrected with minor changes. These changes do not impact the academic content of the article.
Notes
1. Anderson (Citation2012) notes that the use of BMI for assessing health has not been accepted by all in the medical field (202).
2. It is important to note that not only were trans men were more likely to be categorized as “obese” than trans women, but also black and Latinx individuals were significantly overrepresented in the “obese” category (Martinson et al. Citation2020,13).
3. Addressing neoliberal attitudes in advocacy for the reinstatement of Ontario Health Insurance Plan (OHIP) coverage for transition-related medical care, Dan Irving (Citation2012) cautioned that such a strategy could result in access being determined based on individuals’ physical and moral “fitness” (understood in the broadest sense) and ability to be incorporated into capitalist economies.
4. Scholars point to the fact that the fatphobia of physicians often results in their failure to recognize and diagnose eating disorders in fat people (Lee and Pausé Citation2016) that may be contributing to fatness (Brownstone et al. Citation2020).
5. According to Dr. Hugh McLean, a leading surgeon in top surgery procedures in Ontario, dog ears refer to “excess skin and fat that protrudes and puckers from the outermost portion of the incision as it curves around the side of the chest toward the armpit” and “are the most common reason for a revision surgery” (McLean Citationn.d.c).
6. Dr. Armstrong explains that the McLean clinic has this BMI cutoff because it is an outpatient clinic and does not have the capacity to keep patients overnight for observation. According to Armstrong, if a client has a consultation at the McLean clinic and is believed to be too high risk to perform surgery on in the clinic, they will be transferred to WCH instead where they can observe patients, if needed (Women’s College Hospital Citation2023).
7. Frohard-Dourlent et al. (Citation2017) report that at the time of their study BMI restrictions were 35 for all participating Trans Care BC surgeons (45).
8. Harrison’s (Citation2021) Belly of the Beast includes interviews with fat Black trans men, transmasculine, and/or nonbinary people. Harrison’s participants express similar barriers to top surgery as my participants, but also speak to the ways in which anti-blackness has intersected with fatphobia. The racial homogeneity of participants is a major limitation of the study.
9. I mention this because these other health issues may affect surgical outcomes.
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Van Slothouber
Van Slothouber, PhD, recently completed a two-year SSHRC postdoctoral fellowship at the University of Alberta-Augustana. Their work appears in journals including Fat Studies: An Interdisciplinary Journal of Body Weight and Society and the European Journal of English Studies. Their research areas include fat studies, trans theory, queer theory, sexuality studies, and feminist theory.