Gender Dysphoria: When Anti-fat Medical Bias Makes Top Surgery Inaccessible

July 13, 2021

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The warm weather finally showed up after what felt like the longest winter of my life. The global pandemic made everyone feel that way. We shared a collective loneliness over the last year and change. The sunshine allows us to feel warmth in our souls, even when the world is falling apart – if just for an afternoon. But with all of the unbundling from layers of insulation comes a familiar yet unwelcome feeling for some trans folks; gender dysphoria. 

What the Hell do I wear?

Summertime means it’s time to jump back into the constant struggle of what to wear, especially as a fat trans person. What feels most comfortable in the heat doesn’t always affirm my gender presentation. And the options that feel closest to euphoria leave little room for summer activities like hiking, swimming, and sweating, without panic and a whole lot of discomfort. As much as I’d like, swimming in my favorite button down would be wildly inefficient.

Let’s be honest here, dysphoria is all about my chest for me. What’s going to feel most comfortable when managing these big tiddies out at the lake all day? Do I wear a binder? A bra? A tank top? Would a flatter looking chest lead to less misgendering? Would I feel more present when not hyper focused on my chest size; the way my tatas look in a shirt, how they draw attention, how they feel against my sweaty belly? What is it that is making my chest feel so unmanageable and so uncomfortable to me in the first place? Is my gender dysphoria even mine? Have I learned to feel this way because I don’t adhere to the gender binary?

It feels like a big no-no to question gender dysphoria. And that is for damn good reason. Our society has been and continues to target the trans community, treating us like freaks or worse – subhuman, undeserving of civil human rights comparable to that of our peers. Of course we feel defensive of gender dysphoria and its validity. To understand the trans experience we have had to easily define it. We’ve had to fight for respect. We’ve had to fight for medical care and rights. And we’re barely there. In most states in the US, you still have to provide documentation from a mental health professional that you are experiencing true gender dysphoria in order to qualify for gender-affirming surgery.

My experience with gender dysphoria is different as a superfat trans person in this dehumanizing space. The same rules don’t apply to me in my fat body. We don’t talk much about this experience. And I think it’s important to ask this question: how do you achieve gender euphoria when medical transition is not a realistic option?

Gender Affirming Care and BMI

Trans people are vetted before we can receive gender affirmation surgery. We have to prove that our gender dysphoria is real. We have to prove that medical intervention is vital to our wellbeing. Further, we have to show that we’ve been living as our “true gender” in public for at least a year prior to accessing services. We talk about these criteria openly in trans spaces. Oftentimes our spaces include helpful resources of therapists who will make the process as easy as possible for trans folks. What we rarely talk about is the BMI criteria for surgery. Surgery is considered too risky for people with a BMI over 30.

Perhaps this is new territory. Maybe there haven’t been enough superfat people pursuing gender affirming surgery for this to be widely disseminated information. Or maybe it’s because BMI was created by a mathematician to come up with a quick way to determine “obesity,” and actually is not an accurate representation of health or fitness. But my inclination is that this BMI cutoff exists because medical professionals are ultimately, incompetent. Doctors lack training on fat bodies. Fat people are considered too risky to operate on. Our fat bodies suffer the consequences.   

“BMI (body mass index), which is based on the height and weight of a person, is an inaccurate measure of body fat content and does not take into account muscle mass, bone density, overall body composition, and racial and sex differences, say researchers from the Perelman School of Medicine, University of Pennsylvania.”

Why BMI is inaccurate and misleading, Medical News Today

Unfortunately, the BMI categorizes anyone over 30 as obese. This is the threshold for which surgeons base their qualifying criteria on. Are you obese, or not obese? One answer will give you access to life-saving surgery. The other will negate your eligibility. But, if there are notable sources pointing out the flaws and inaccuracies of BMI metrics, how are we defining health, then? What makes someone fit for surgery? It makes me wonder if the issue is about an individuals’ health and readiness to handle a risky surgery. Perhaps it has more to do with liability and lack of research on fat bodies, rendering the medical industry incompetent of treating nearly a third of the US. They know they’re incompetent, which is why all care comes to a screeching halt at a BMI of 31. 

Sometimes folks do talk about the BMI requirement in trans support spaces. Trans folks boast of finally finding a surgeon who did not act as a gatekeeper to their medical care and for a moment, I feel hope. The issue here however, is that the most progressive of surgeons will make exceptions for the BMI requirement, allowing folks up to a BMI of 35 or 36 to access care.

This is wildly discouraging for someone like myself, with a BMI of over 90. What are my chances of finding a doctor who’s willing to go so far for me? And further, can I trust that a doctor is capable of a safe procedure if they’ve never been trained to treat a body like mine?

Preparing for surgery at what cost?

In order to get top surgery, I’d need to compromise other values. Surgeons would require me to lose a significant amount of weight before approving my surgery, just like they require for major weight loss surgery. The means of which fat people are pushed to achieve extreme weight loss is alarming. The protocol for fat people pursuing weight loss surgery is to have them lose as much weight as possible before they can even get on the table. This process includes extreme dieting, starvation, malnutrition, and forceful exercise. These steps are required. This leaves the patients’ overall health in complete disrepair. But hey, at least at the end they’ll be skinny. 

I will not pursue intentional weight loss. I have a deep commitment to untangling anti-fat narratives and internalized fatphobia. I’m also someone learning how to recover from an eating disorder and repairing my relationship with food. To be told that I’d need to lose hundreds of pounds before they’d consider my request for top surgery would mean leaning rapidly into my eating disorder and further damaging my body, spirit, and mental health. Anti-diet work has brought me such peace around food and weight. I’m simply not willing to compromise on my commitment to body liberation and unpacking anti-fatness.

Where do people like me go from here?

Top surgery will probably never be accessible to me. And I may never see a world where other superfats can safely access gender affirming surgery. I’m in the process of making peace with that and I’m not going to lie, it’s sort of devastating. And complicated. I want to be happy for my trans friends, who post photos of their shirtless, flat chest on the beach. But I find myself feeling discouraged and conflicted.

I know I would feel more comfortable with a flat chest. But why? Would the world see me as more androgynous and perhaps pause more often than not when determining what pronouns to use for me? Might more folks choose to speak of me neutrally based on my mix of attributes? Would I enjoy how my shirts feel, would I feel inner peace, would I be closer to gender euphoria? Yeah, I sure would. But how long do I chase gender euphoria through oppressive systems before I have to decide to try another route? 

So, I’m working on radical acceptance. Radically accepting my fat body and radically accepting my trans body, as it is. This is radical because I have what I would call “triple D tiddies.” I refuse to wear bras for support, as that heightens my dysphoria. There’s really no way to hide these bad boys and I’m sick of trying. I have never been one to believe that in order to truly be trans you have to transition at all – never mind having to fit into a binary definition of what a certain gender looks like. I have feminine nonbinary friends who love their chests and use neutral pronouns. They are valid and truly nonbinary. I have transfeminine friends assigned male at birth who will never get bottom surgery. They are still valid and truly trans.

What could the world look like if we didn’t need surgery to be seen as we are? How about the quality of our lives without the pressure to adhere to binaries? What if breasts were not an indication of a certain gender? There are men with large chests and women without. I have quit chasing euro-centric beauty standards of thinness. It’s exhausting. That life made me feel caged and unwell. Chasing the gender binary is a trap. I want liberation from that cage as well. I don’t fit into that box and I’m sick of fighting myself about it!

And finally, let us not forget that systemic white supremacy is at the root of all fatphobia, BMI, and even binary sex and gender definitions. I am working on untangling my values from those rooted in white supremacy and there is a lot to be done.

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