BMI Cutoffs are unscientific and harmful

As I’ve written about before, BMI (Body Mass Index) is an unscientific concept that is often used to deny trans people life-saving surgeries. It is treated by far too many surgeons as medical fact, despite the vast body of evidence that it is wildly inaccurate, scientifically useless, and never intended by the creator to be used on an individual basis.

Recently, the only surgeon in Washington State, Geoffrey Stiller, formerly one of the few surgeons who would accept fat patients, updated his policies quietly to exclude people over the arbitrary and oft-used cutoff of 35 BMI. That means that at least two people close to me are now being denied gender affirming surgery without so much as a notification about the change. So I wanted to take the opportunity to share some scientific research recently published on the topic.

  1. Recent research shows that there is no correlation between BMI and surgical complication rates in trans people in either vaginoplasty (bottom surgery) or mastectomy (top surgery)
  2. “Obesity” (aka normal body variation) is very common in trans people seeking surgery (26% at Mount Sinai) and did not change despite efforts to lose weight prior to surgery
  3. BMI is not an empirically based method of denying gender-affirming surgery

Trans people should not have to bear the burden of educating providers about our care but all too often we are put in that position anyway. So next time a surgeon tells you they won’t perform surgery because of “policies”, please feel free to use this research to push back on them. Even if you don’t win a single conversation, hopefully you will plant a seed and prompt them to actually read the scientific literature on the topic. I found these articles with only a cursory review of the topic and I’m not even a doctor.

Citations

  1. Ives GC, Fein LA, Finch L, Sluiter EC, Lane M, Kuzon WM, Salgado CJ. Evaluation of BMI as a Risk Factor for Complications following Gender-affirming Penile Inversion Vaginoplasty. Plast Reconstr Surg Glob Open. 2019 Mar 13;7(3):e2097. doi: 10.1097/GOX.0000000000002097. PMID: 31044103; PMCID: PMC6467628.
  2. Rothenberg KA, Gologorsky RC, Hojilla JC, Yokoo KM. Obesity is Not Associated with Complications or Revisions after Gender-Affirming Mastectomy in Transgender Patients. Plastic and Maxillofacial Surgery. 2019 Oct 1;229(4):sup1. doi: https://doi.org/10.1016/j.jamcollsurg.2019.08.494
  3. Martinson TG, Ramachandran S, Lindner R, Reisman T, Safer JD. HIGH BODY MASS INDEX IS A SIGNIFICANT BARRIER TO GENDER-CONFIRMATION SURGERY FOR TRANSGENDER AND GENDER-NONBINARY INDIVIDUALS. Endocr Pract. 2020 Jan;26(1):6-15. doi: 10.4158/EP-2019-0345. Epub 2019 Aug 28. PMID: 31461357.
  4. Lisa M. Brownstone, Jaclyn DeRieux, Devin A. Kelly, Lanie J. Sumlin, and Jennifer L. Gaudiani. Transgender Health. ahead of printhttp://doi.org/10.1089/trgh.2020.0068

Surgical Consults

I have a date for gender confirmation surgery! August 3rd, 2020.

I’ve decided to go with Dr. Heidi Wittenberg for my vaginoplasty. She is who I have been researching for the past year and my consultation with her last week confirmed that she is everything I had been hoping for. Her staff were all wonderful and friendly. And she was very approachable with a great bedside manner and excellent at explaining the process and answering questions. She seems very factual and will be straightforward with the risks and complications. She also has the training in alternate techniques such as peritoneal pull through that would allow her to perform a revision surgery with the latest technology if that was needed. More importantly, she feels like someone I can trust completely and it makes sense to me to have a woman with a background in gynecology and urology doing my care.

I did do a second consultation while I was in San Francisco with Dr. Thomas Satterwhite who trained with Dr. Wittenberg at Brownstein and Crane. He comes highly recommended from friends but I didn’t have the greatest experience with him. In both his intro video and in person he was very fixated on BMI (Body Mass Index) and treated it as medical fact, despite the vast body of evidence that it is wildly inaccurate, scientifically useless, and never intended by the creator to be used on an individual basis. He brought it up multiple times in my 20 minute consult to warn me that if I gained 10 lbs before next summer, I would be ineligible for the surgery. And yes, I have what many people would consider excess fat around my belly, but I am not objectively that fat of a person. I am tall and large and I am built that way naturally. In fact, I am pretty average in build for a white American.

If I, who have quite a bit of relative privilege, am receiving this much fat phobia from him, how much more pronounced would that be for the many trans people who are larger than me? And if he puts stock in pseudoscience like the BMI, what other areas does he make inaccurate conclusions in? To me, this is the kind of thing I would expect from a plastic surgeon that makes money off of fatphobia. And maybe that’s his background, but I’m not giving him money to support that. Even if he was the best surgeon around. Luckily, I have choices.

Now I’m not saying other people haven’t had wonderful experiences with Satterwhite, but I loved Wittenberg and I’m excited to be having her do my surgery. Next up, I am submitting documentation to get laser hair removal done on my genitals to prepare the area for surgery. Then I need to get 3 letters from my physician, therapist, and a PhD level psychiatrist because my insurance still goes by the outdated WPATH standards of medical gatekeeping.

In the meantime, I’m starting my countdown now for surgery. 377 days!

If you would like to contribute to my transition fund, you can donate at: https://www.gofundme.com/f/haven-gender-confirmation-treatments