This commentary is by Robin Zabiegalski (they/them), a writer in Burlington who currently writes features on health, fitness and wellness for Health Digest. Their work has been featured in several digital publications and Seven Days.
Vermont is continually ranked in the top five best states for trans folks, and we’ve earned that ranking. In 2013, Vermont lawmakers passed legislation that requires insurance companies to cover gender-affirming care. In 2019, they revised that legislation to include trans youth and expanded Medicare coverage for gender-affirming surgeries.
These laws demonstrate Vermont’s strong commitment to accessible, affordable trans health care. Unfortunately, these laws don’t actually help fat trans people.
I use the word fat as a neutral descriptor, the same way I use the words “short” or “tall.” I describe myself as fat because one look at me confirms that I am. I’m also nonbinary. I was assigned female at birth, but I’m not a woman. I’m not a man either. My gender is somewhere in between. Exactly where? I’m not sure, and I don’t have to be. Sometimes gender is more about knowing what you’re not than it is about knowing what you are.
Like many nonbinary people, I experience gender dysphoria, which the Diagnostic and Statistical Manual of Mental disorders defines as a “marked incongruence between their experienced or expressed gender and the one they were assigned at birth.” Part of my experience of gender dysphoria is chest dysphoria, discomfort with my breasts that takes a significant toll on my mental health. Because of this, I want masculinizing top surgery — a gender-affirming procedure that removes breast tissue and shapes the chest to appear more masculine.
When I started researching how to get top surgery in Vermont, I discovered that only one practice in the entire state is currently advertising top surgery services. A couple of more doctors are listed in a UVM guide to gender-affirming care for Vermonters, but one of those surgeons is at Dartmouth-Hitchcock in Lebanon, New Hampshire, and the other doesn’t appear to be performing top surgeries anymore.
So, I reached out to the one practice in Vermont that definitely does top surgery. I did so with much trepidation, because I know that many surgeons refuse to perform top surgery on fat people. One study found that surgeons cite many reasons for their refusals, including the increased risk for surgical complications and the need for “revisions,” additional surgeries to correct poor results from the initial surgery.
Research does support that surgery is riskier for fat people. However, much of the current research doesn’t explore why fat patients have more negative outcomes during and after surgery. One possible explanation is that it has less to do with body size itself and is more a result of medical weight stigma, a well-documented phenomenon.
Research has shown that medical professionals believe abhorrent things about fat people, and it directly impacts the way they care, or don’t care, for fat patients. Many medical professionals, especially surgeons, just deny fat people medical care by setting BMI limits on procedures. The antiquated “Body Mass Index” still informs the medical definition of “fat.” Though the BMI was never intended to be used as a measure of health, has deeply racist origins, and is not an evidence-based indicator of individual health, it is still widely used to prevent people from accessing medical care.
And that’s exactly what happened to me. The top surgeon’s office informed me that I wouldn’t even be able to get a consultation with the surgeon until my BMI was below 35. I would have to lose 70 pounds before I could even talk to the surgeon.
BMI limits like this on top surgery aren’t even evidence-based. Studies have found that fat trans people don’t experience complications at a higher rate than thinner trans people and don’t actually require revisions more often. The most current research definitively shows that weight should not be a barrier to receiving gender-affirming surgeries.
You may be thinking, “Just lose the weight!” You wouldn’t be alone. Most people believe that dieting and exercising lead to sustainable weight loss, but the science shows that isn’t true. So does my personal experience. I’ve lost and regained more than 50 pounds several times in my life due to eating disorders. Every time I lost weight, I regained it as soon as I began to eat normally.
The only way I was ever able to stay thin was through starvation and compulsive exercise. When I finally got treatment for anorexia and exercise bulimia, I got fat, and I’ve stayed fat.
Weight loss isn’t an option for me, and because of that, I can’t get top surgery in Vermont. I’ll have to travel out of state, which adds significant travel expenses, especially since I’ll have to remain out of state while I recover. A caregiver will have to stay with me while I recover in a hotel instead of at my house, and it can’t be my partner, since he’ll have to be home with our 3-year-old.
In one of the most “progressive,” “trans-friendly” states in the country, my fatness still prevents me from getting medically necessary gender-affirming care. Is this how we want to care for our neighbors?
