Trans people are used to fighting for access to gender-affirming health care – but for some, fatphobia is yet another barrier.
Running the gauntlet of NHS gender identity clinics for hormone replacement therapy and surgeries has become a trans rite of passage – one that’s especially fraught if you’re a person of colour or marginalised in other ways.
Being fat is one such factor that can lower your prospects of medically transitioning. Although known to be inaccurate, particularly for people of colour, Body Mass Index (BMI) is used across NHS and private medical services to determine eligibility for life-changing surgeries. Since the metric can be the deciding factor for access to top surgery or genital operations, you’d expect it to be applied consistently across health services. But contradictory application of BMI requirements is commonplace.
Nathan, 25, is a trans man who developed an eating disorder after being made to lose weight for top surgery.
He could’ve avoided a gruelling crash diet had he been told BMI limits vary across surgeons. “They didn’t tell me that Brighton’s BMI limit is 35 and Plymouth’s limit is 40,” he told PinkNews. “If I had gone to Plymouth, I wouldn’t have been asked to lose weight at all.”
Nathan rapidly lowered his BMI from 38 to 35.8 through an intense 20-hours-a-week exercise and no-carb regime. He was so active he began building muscle at a rate preventing weight loss. This still wasn’t satisfactory so he was asked to lose a further two kilos in 10 days to qualify for surgery.
Another person I spoke to was prescribed an unusually low oestrogen dose on the NHS – she was told her weight meant she couldn’t take the normal dose. She topped up using hormones sold illegally online for years until a different doctor insisted there was no BMI-related risk, immediately upping dosage to normal levels.
Inconsistent BMI demands among doctors and surgeons undermine the idea that it is, on its own, a robust, accurate indicator of health risk when medically transitioning.
BMI is just one (questionable) measurement of a person’s overall health. But it’s what surgeons often focus on – to the exclusion of other important factors. Worryingly, everyone I spoke to confirmed the same thing: eating disorders were unilaterally neither raised, nor considered by surgeons asking patients for drastic weight loss. Yet it’s well documented that trans people suffer eating disorders at a higher rate to cisgender peers.
Several of the people I spoke to had eating disorders which made undertaking significant weight loss unsafe. But they felt pressured by clinicians to try yo-yo or fad diets, with one surgeon reportedly suggesting a diet to “lose 10 kilos in a month”. Another recalled a phone conversation with a receptionist where they were told they “shouldn’t be eating hummus because it has a high carb count”.
There’s just utter despair sometimes that I’m just never gonna get the things that I need.
Disability is another factor often disregarded by surgeons. Lee Hulme, 38, had a knee injury and back pain (later diagnosed as a slipped disc) when told they needed to lose weight for lower surgery. That was four years ago. The non-binary transmasc has since developed sciatica and arthritis. Hulme can’t get surgery until they lose weight, despite exercise-limiting conditions: “There’s just utter despair sometimes that I’m just never gonna get the things that I need.” Another person I spoke to is in a similar boat – born with a heart defect which makes exercise dangerous.
If eating disorders, crash diet risks and disabilities are strangely absent from health considerations around surgery, so too, is suicide. Stonewall says that one in four young trans people have attempted suicide; the 2015 US Transgender Survey put the number of trans adults who had attempted suicide in their lifetimes at 40 per cent.
Bex Stinson, 33, has waited almost 10 years for vaginoplasty on the NHS and says it feels like “you’re going to have to die with those genitals”.
She continues: “Surgeons aren’t taking into account the fact that I have mental health conditions, the fact that I have high suicidality risk, the fact that I have an eating disorder, the fact that I have several comorbidities.” Her dysphoria has led to self harm, and she very nearly died by suicide attempt. For Stinson, and others, if the option is suicide or elevated risk on the operating table, the latter should be considered.
It follows then that most people I spoke to felt BMI requirements were neither about health, nor patient needs. They report clinicians speaking of BMI limits giving ‘best results’ according to their own personal aesthetic taste, rather than ‘best results’ for alleviating patient dysphoria. I was told of one surgeon who said his patient’s lower surgery “won’t look big and won’t look right unless you lose weight.” The surgeon insisted weight loss was essential so the patient could urinate standing up, but standing to pee wasn’t what the patient wanted.
Gender-conforming bodies are slender and thin.
For Dr Francis Ray White, a non-binary sociologist and fat studies scholar, losing weight for best results is about surgeons “wanting to create a body that is cis-passing and gender-conforming and fat bodies don’t gender conform.” This is because “generally, gender-conforming bodies are slender and thin.” The academic also argues “there’s a sense in which the fat trans person can never exist because nobody will create them surgically”.
The statement feels uncannily tied to the story of 27-year-old non-binary transmasc and Free Black Uni founder Melz. They’ve been denied gamete storage on the NHS due to BMI requirements. It implies that fat trans people cannot surgically exist, nor can they procreate.
Of course reproductive fatphobia doesn’t just affect trans people, it affects cis people too. Medical fatphobia harms us all. This year the Women and Equalities Committee released a report concluding that “BMI actually contributes to health issues such as eating disorders and people’s mental health by disrupting body image and inviting social stigmas”. It also called for the use of BMI to be stopped and a “health at every size” approach to be adopted.
Until BMI is retired, fat trans people will remain stranded mid-transition, their lives put on hold for years. Everyone I interviewed who attempted weight loss didn’t just gain it back, but gained more, leaving them with decreasing hopes of surgery over time and fulfilling the widely accepted claim that diets don’t work long-term. I think of the trans woman I interviewed who’s never been swimming with her children (now aged 17), after being refused lower surgery almost a decade ago. There has to be another way: one based on holistic healthcare, patient needs and informed consent rather than an inaccurate 19th century metric.
PinkNews contacted the NHS clinical commissioning groups that cover Brighton and Plymouth for comment.
Beat is the UK’s eating disorder charity. It runs a national helpline for people who have or are worried they have an eating disorder, and for other people affected such as family members and friends. Find out more here
Suicide is preventable. Readers who are affected by the issues raised in this story are encouraged to contact Samaritans on 116 123 (www.samaritans.org), or Mind on 0300 123 3393 (www.mind.org.uk). Readers in the US are encouraged to contact the National Suicide Prevention Line on 1-800-273-8255.