Body mass index (BMI) requirements for gender-affirming surgeries can sometimes present an obstacle to gender transition surgery for many transgender and gender diverse people. Sean Iwamoto, MD, and John M. Taormina, MD, two of the authors of a recent Journal of Clinical Endocrinology & Metabolism paper, discuss the need for a multidisciplinary approach for these patients.
Last November, Sean Iwamoto, MD; John M. Taormina, MD; and their team of colleagues comprising providers from across the country, presented a talk titled, “A Closer Look at Body Mass Index Requirements for Gender-Affirming Surgeries” during a plenary session at the U.S. Professional Association for Transgender Health Scientific Symposium in Colorado, during which a gender-diverse patient shared their own experience facing barriers to a gender-affirming surgery because of BMI requirements.
Soon after, Iwamoto, Taormina, and their co-authors were invited by the editors of The Journal of Clinical Endocrinology & Metabolism to submit a different but similar case as an Approach to the Patient article. For this paper, the authors detailed the case of a 20-year-old White non-Hispanic nonbinary patient designated female at birth. The patient, who uses they/them pronouns, presented to the endocrinology clinic because they wanted to discuss weight management for gender-affirming bilateral mastectomy.
Multiple surgical centers had already turned the patient away, either because a center did not perform gender-affirming surgeries (GAS), or because a center required the patient to lower their body mass index (BMI). The patient initially tried lifestyle modifications — counting calories, exercise — but their chest caused back pain (the reason for seeking the mastectomy) and limited activity, so they resorted to more extreme forms of dietary restrictions, hoping to quickly shed the weight. Weight loss was ultimately unsuccessful, which meant the patient couldn’t access GAS, and their depression worsened to including thoughts of self-harm. In the case presentation, the authors write, “[The patient] presented to the clinic frustrated and asked for support.”
The authors go on to point out that this case is representative of a transgender or gender diverse (TGD) person’s experience with barriers to GAS. What’s more, there’s a dearth of actual evidence to support these BMI requirements as a requisite to GAS. “This paper grew out of a recognition of the complexity of weight management and weight recommendations for TGD people and concerns regarding the lack of literature supporting presurgical BMI cutoffs,” says Taormina, who identifies as gay, and is an assistant professor of family medicine at the University of Colorado Denver – Anschultz Medical Campus as well as an obesity medicine specialist at the Anschutz Weight Management and Wellness Clinic.
Acknowledging Patient Barriers
Global interest in GAS has increased in the past two years, according to the authors of the JCEM paper, and that has led to an increase in procedures in the U.S. Taormina says that the reason for the increased interest is multifactorial, but the largest contributor to this shift is the increased access to the procedures. More surgeons are offering GAS, and more insurance carriers are paying for them.
As that interest grows, so too does the need to be aware of the obstacles TGD patients face beyond BMI restrictions — insurance, legislative, and geographical barriers. “Some endocrinologists may only manage gender-affirming hormone therapy, but others may end up also taking care of non-GAHT concerns such as primary care, PrEP, mental health, and also advocating for patients in accessing GAS,” says Iwamoto, who also identifies as gay and is an assistant professor of medicine at the University of Colorado Denver – Anschultz Medical Campus, and a staff endocrinologist at the Rocky Mountain Regional VA, Denver, Co. “Thus, it is increasingly important for endocrinologists to be aware of the barriers that their patients face in accessing all aspects of gender-affirming care.”
But again, as the JCEM authors write, these BMI requirements (usually set between 30 and 35 kg/m2), are a significant barrier to TGD people, since they are more likely to have obesity than cisgender people, and as in the case above, recommendations to lose weight could lead to disordered eating.
And since disordered eating can help alleviate gender dysphoria in many TGD patients by leading to body changes that can be affirming, such as a desired body shape or menstrual cessation, it is important for providers to be aware of this, because eating disorders are prevalent among TGD people. “Providers should screen patients for a history of disordered eating before discussing weight management and should refer appropriate patients to qualified eating disorder specialists when indicated,” Taormina says.
A Need for a BMI Standard
Neither the Endocrine Society nor the World Professional Association of Transgender Health identify BMI requirements, and the JCEM authors write, “BMI requirements for GAS run counter to current efforts by the American Medical Association to understand health outcomes and risk beyond BMI.”
“Some endocrinologists may only manage gender-affirming hormone therapy, but others may end up also taking care of non-GAHT concerns such as primary care, PrEP, mental health, and also advocating for patients in accessing GAS. Thus, it is increasingly important for endocrinologists to be aware of the barriers that their patients face in accessing all aspects of gender-affirming care.” — Sean Iwamoto, MD, assistant professor of medicine, University of Colorado Denver – Anschultz Medical Campus; staff endocrinologist, Rocky Mountain Regional VA, Denver, Co.
Taormina tells Endocrine News that BMI requirements are typically enforced due to concerns about patient safety (e.g., wound infection, venous thromboembolism) and aesthetic outcomes. And that while available retrospective studies do not support that these outcomes are significantly different among patients with obesity compared to those without obesity, surgical centers may have multiple reasons for continuing to enforce BMI criteria.
“These concerns can include a surgeon’s skill and experience operating on larger bodies, access to appropriately sized equipment (e.g., tables, instruments), and anesthetic concerns regarding proper ventilation and medication dosing,” Taormina says. “Expanding medical/surgical training to the care of patients with obesity and increasing availability of appropriate equipment can alleviate many of these concerns. Prospective and multi-site studies are also needed to further investigate the perioperative risks of GAS in patients with obesity.”
Iwamoto, a former co-chair of the Endocrine Society’s Transgender Medicine and Research Special Interest Group, says that there have been recent calls among clinicians, scientists, and patients to include TGD patients from the very beginning when thinking about research studies, clinical care optimization strategies, quality improvement projects, etc. “It is equally important to work with and promote TGD clinicians and scientists who are also working hard on studies to ultimately improve TGD patients’ healthcare experiences and health outcomes,” he says.
“This movement is in response to a recognition that TGD people know what is important to TGD people better than the medical or scientific community at large,” Taormina says. “GENDER-Q is one example of such a tool being developed in collaboration with TGD people to assess outcomes among TGD people.” [see box]
Until those studies are completed, centers like the UCHealth Integrated Transgender Program at University of Colorado Anschutz Medical Campus are caring for many transgender and gender diverse patients who are denied GAS due to strict BMI criteria. “We have implemented weight management services into our multidisciplinary gender-affirming program to try to meet this need,” Taormina says.
Iwamoto points to an article he co-authored from June 2022 in Transgender Health that further describes the multidisciplinary model of care that UCHealth Integrated Transgender Program that’s housed within the broader endocrinology clinic where patients may have appointments on the same day with endocrinology, weight management, primary care, gynecology, plastic surgery, psychiatry, psychology, and social work. “A multidisciplinary integrated clinic is a feasible and desired step toward improving health care for the TGD population,” the authors of that paper write.
A Need for Multidisciplinary Care
For TGD people, the multidisciplinary approach is paramount. The patient agreed to pursue medical weight management to qualify for GAS, but they were concerned about calorie counting and their history of disordered eating, so they were referred to an affirming psychotherapist who specializes in addressing gender dysphoria and disordered eating. “A multidisciplinary approach to patient management provides more holistic care than can be provided by one person,” Taormina says. “It allows adequate time and focus to address all aspects of patient care. This is important in perioperative planning and risk assessment, as there are risks beyond traditional surgical complications, including nutritional risks and mental health risks.”
And that multidisciplinary approach should incorporate shared decision-making. Some patients may not wish to lose weight – they may feel more comfortable in a larger body, or they may have struggled with an eating disorder, or they simply aren’t ready to start lifestyle modifications or don’t have the means to do so. Taormina says that TGD people might find a larger body more affirming; transfeminine people may desire larger breasts. On the other hand, transmasculine people may want to conceal their breasts.
“A multidisciplinary approach to patient management provides more holistic care than can be provided by one person. It allows adequate time and focus to address all aspects of patient care. This is important in perioperative planning and risk assessment, as there are risks beyond traditional surgical complications, including nutritional risks and mental health risks.” — John M. Taormina, MD, assistant professor, family medicine, University of Colorado Denver – Anschultz Medical Campus, Denver, Co.
“I discuss postoperative goals with patients before surgery to develop post-op behavior and medication plans and to preemptively address anticipated challenges,” Taormina says. “I encourage weight maintenance in the immediate pre-and post-operative periods for improved recovery and wound healing. My overall focus is to listen to patient preferences while also promoting lifelong healthful behaviors and monitoring for changes in health markers (i.e., glycemic control, lipid profile, blood pressure). Weight changes can occur quickly, so I generally see patients four to six weeks after their procedure and then continue to see patients at least every three months for the next year or so to continue to monitor behaviors and adjust medications as needed.”
For now, Iwamoto says he hopes the medical community understands the importance and benefits of multidisciplinary care, as it relates to holistic gender-affirming care and weight loss/weight management strategies for TGD patients. “Patient voices are even more important in these types of projects and publications,” he says. “Also, the appreciation we have for our UCHealth Integrated Transgender Program Community Advisory Board’s input in clinical and research activities of the program, including those related to BMI requirements for gender-affirming surgeries, cannot be understated.”
Taormina goes on to say he wants to bring awareness that BMI alone is insufficient to determine an individual’s surgical or medical risk. While adiposity can certainly affect health and surgical outcomes, each individual’s risk must be assessed on a case-by-case basis. “Surgical risks must be weighed against the risks of delaying surgery and the risks of forcing weight loss to access lifesaving care,” he says. “For many, gender-affirming surgeries are lifesaving surgeries.”
—Bagley is the senior editor of Endocrine News and writes the monthly “Trends and Insights” section. He has been with the Endocrine Society since 2013.
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