Studies show top surgery is safe for fat patients, but some surgeons still mandate weight loss

Vince Wescott was ready for top surgery. He had the cash saved up, he’d gotten a letter from his therapist, and he’d sent in the required photos of his chest and torso in preparation for a consultation.

When his surgeon’s office called unexpectedly, he picked up, assuming that they were missing paperwork or needed to reschedule. But he was met by the panicked voice of a nurse.

“The doctor had a look at the pictures and your weight is very concerning,” Wescott remembers her saying. “He is not going to be able to do this unless you lose about 100 pounds.”

His good health history didn’t matter. “My vitals, my bloodwork, everything, it’s all good. I’m just fat.” But the doctor had determined, like so many before him, that Wescott, 32, had to lose weight.

Wescott’s surgeon isn’t alone — many surgeons refuse to perform chest masculinization surgery on people at high weights, patients and other physicians told STAT. In fact, a 2021 study published in Transgender Health called weight-based restrictions ubiquitous. Fat transmasculine people said they are all too aware that even if they can make it past the normal hurdles — insurance approval, saving or crowdfunding the thousands of dollars to cover fees, and time off from work — their body size could still jeopardize their access to surgery.

The reasons vary. Some surgeons bring their own biases into the rejection, telling patients they won’t like their results unless they lose weight. Many cite complication rates, pointing out that people with higher BMIs are at greater risk of complications after surgery. Some set strict cutoffs, refusing to operate on people with BMIs above a certain range.

“You might have everything that would set you up for success,” said Fan Liang, the medical director of the Center for Transgender and Gender Expansive Health at Johns Hopkins. “But then there’s the BMI cutoff and all of a sudden you don’t have any surgical options ahead of you.”

But increasingly, research is showing that top surgery is safe. The complication rates for patients with higher BMIs aren’t much higher than those for patients with lower BMIs. That’s in stark contrast to other gender-affirming surgeries, like facial feminization, breast augmentation, and genital (bottom) surgeries, which can be much more prone to complications for patients with higher BMIs than for others.

Most surgeons groups, including the American Association of Plastic Surgeons and the American Surgical Association, and the medical organization World Professional Association for Transgender Health, didn’t respond to STAT’s request for comment about restrictions and limits on gender-affirming care for patients with high BMIs. The American Society of Plastic Surgeons said it defers to individual members when it comes to BMI limits.

”Surgeons look at individuals on a case-by-case basis and make decisions based on the individual circumstances at hand,” said Loren Schechter, a member of ASPS and the medical director of the Gender Affirmation Surgery Program at Rush University Medical Center. His practice dropped its BMI restriction for top surgery more than five years ago, “but some people do use them as a reference range or a guide.”

The refusals can have severe mental health repercussions. Weight stigma more broadly has been shown to trigger depression, suicidal ideation, and disordered eating behavior, and trans people are already at higher risk for suicide and eatings disorders.

When Wescott was told he’d have to lose a third of his body weight, “It was like getting hit by a train,” he said. “It took everything out of me, I really didn’t want to live at that point.”

Chala June, 27, made it into the doctor’s office in Brooklyn, N.Y., also in 2021, before they were turned away. The surgeon looked at June’s chart, pulled out her phone to calculate their BMI and said, “Come back in six months, try to lose 50 pounds and then we can talk.” She offered to schedule them for a gastric bypass consultation. June wondered, “How am I able to undergo that major surgery, but I can’t get a life-affirming surgery?”

It triggered a downward spiral. “I experienced suicidal ideation in a way I hadn’t in a while,” June said. “That was a really hard thing to bounce back from.”

The BMI (body mass index) was developed in the 1830s by a Belgian astronomer and mathematician who studied the height, weight, and chest circumference of French and Scottish soldiers. He intended it as a population-level measure to determine the average or “ideal” man — not as a proxy for individual health, as so many use it today.

“It’s like square footage in a house,” said Alexes Hazen, a gender-affirming plastic surgeon at NYU Langone Health. “It tells you some information, but it doesn’t tell you what the layout is.”

Despite this, a BMI in the obese range can spark a litany of assumptions about a person’s health. “For some people, it’s actually a mild problem and doesn’t necessarily have many consequences in terms of health, but for some others it could be one of the most severe things,” said Francesco Rubino, chair of metabolic and bariatric surgery in the Faculty of Life Sciences & Medicine at King’s College London.

Statistically speaking, a high BMI consistently increases complication rates across plastic surgery, in everything from facial surgery, abdominal wall reconstructions, and breast augmentation, reconstruction, and reduction to phalloplasty (construction or reconstruction of the penis) and vaginoplasty (construction or reconstruction of the vagina). For patients with obesity, anesthesia poses a variety of risks related to breathing and airway management, cardiovascular function, and proper dosage; operations take longer, too. These patients face higher rates of infection, longer healing times, and other challenges with post-operative care.

But new research shows that having a high BMI is not a major risk factor in top surgery. A 2021 study from Georgetown University found that although rates of minor complications are higher for patients with obesity, acute complications from top surgery are comparable for patients with and without obesity.

Of the high-weight patients in the study, 31.5% had minor complications compared to about 12% for patients considered normal weight. These complications included infection, hematoma (the accumulation of fluid), and aesthetic issues, such as partial nipple graft loss and dog ears (where excess skin or fat puckers at the end of an incision). Less than 6% of patients had the more major complication of full nipple graft loss. Minor complications can often be resolved in follow-up office visits. No patients needed to return to the operating room.

“When you look at the data and you look at complications resulting from top surgery, BMI really doesn’t factor into it much at all,” said Liang, the Johns Hopkins physician. “Patients don’t have increased risk of bleeding, of prolonged hospital stay, or returning to the hospital in the emergency room setting.”

Studies from University of California, San Francisco-East Bay and Ottawa Hospital Research Institute also showed that the potential benefits of top surgery outweigh the potential risks for patients with obesity. A 2019 study on Hazen’s patients, published in the journal Plastic and Reconstructive Surgery, found that “top surgery had major positive effects on all mental health and quality-of-life metrics.”

“You have caused a tremendous improvement in this patient’s dysphoria and mental well-being in exchange of having perhaps a small area of a nipple graft that eventually will heal,” said Gabriel Del Corral, a plastic and reconstructive surgeon and the lead author on the Georgetown study. “If I put that to most surgeons and most patients, I think everybody will deem that as an acceptable risk.”

“We have proven that it’s safe to offer [top surgery] for those high BMI patients,” he added.

In fact, top surgery might be safer for patients who would not be good candidates for breast reduction or breast augmentation, according to Del Corral. Every surgeon who spoke with STAT emphasized that weight-related screening is still important for many gender-affirming procedures, including bottom surgeries such as phalloplasty and vaginoplasty, where high body weight can compromise outcomes.

“We do have limits for bottom surgery because the complication profile is more significant,” said Liang. “When it comes to bottom surgery, having a higher BMI makes the outcome less predictable.”

Both Liang and Del Corral said that BMI cutoffs were born out of an abundance of caution from surgeons with little to no experience with gender-affirming surgeries. As top surgery has become more prevalent, doctors have gained experience and comfort with the procedure and have been able to expand who they feel confident operating on. Plus there’s now more data available to bolster that confidence.

“The reason it changed is not because people changed their mind. It’s because now we’re actually looking at things objectively,” said Del Corral. “Instead of applying the same sort of old-school methodology of a BMI threshold, we’re looking at things physiologically from beyond just the number.”

There may be another reason plastic surgeons don’t want to operate on certain patients: their own anti-fat bias.

When Azrael Dean Martinez, 40, went to their top surgery consultation, the surgeon pushed them to lose weight — but her reasoning was based on aesthetic concerns, not on any discussion of potential risk or complications.

They remember her saying, “I refuse to do anybody at your weight because you won’t be happy with the results.”

Martinez thought the surgeon was making judgements about their body based on her taste, rather than their needs. “It felt like talking to a wall,” Martinez said. “I felt body shamed.”

They had stopped regularly exercising in the years before the consultation, as their dysphoria worsened. They knew working out would help them lose weight, but working out made them hyper aware of their chest. They thought weight loss would be easier after surgery, but they couldn’t have surgery until they lost weight.

Ellie Zara Ley, a gender-affirming surgeon in California, said that surgeons allowing their preconceived ideas to overshadow the needs of their patients is a problem across the industry. “I think they bring in their own bias, which basically means that if you’re fat, you’re just not going to look good no matter what,” she said. As one of the few gender-affirming surgeons who is also a trans woman, she feels deeply for the patients being denied care. “You have to go into this wholeheartedly. It’s not just a job, you really have to care for the community and the people in it.”

Doctors can also underestimate the necessity of top surgery. “For a lot of plastic surgeons, it’s viewed as elective,” Hazen said. That mindset allows surgeons to justify delaying or denying care and can influence them to focus on aesthetics over access.

Many transmasculine people say they’d prefer a flat chest with ugly scarring over having breasts. “I could look like I got mauled,” said June, the patient in Brooklyn. “I’ll put a T-shirt on, just take them away.”

Anti-fat bias is a common and well-documented problem in medicine. The bias has serious psychological effects on fat patients, including increased suicidal ideation. Research also shows that bias has serious physical effects, including on the heart, thyroid, and the endocrine system.

And anti-fat bias is often compounded by transphobia and racism, leading to worse health outcomes for those with multiple marginalized identities.

“People don’t feel heard. People don’t feel listened to. It’s an equipment thing. It’s a comments thing. It’s a judgment thing. It’s an assumption thing,” said Mary Himmelstein, an assistant professor at Kent State University who researches weight stigma.

Both Wescott and June are deeply familiar with this bias in the medical community. In 10th grade, Wescott was playing volleyball when he landed wrong, twisted his ankle, and “snapped it like a chicken bone.”

The MinuteClinic doctor was unconvinced. “Oh, it’s not broken, it’s just sprained, you just need to lose weight,” Wescott remembers hearing. Luckily, his mom was there to advocate for him. The doctor ordered an X-ray, which showed a broken ankle.

“It was very much a window into the next years of my life,” Wescott said. “Every single time I went to the doctor, regardless of what it was for, the note was always, ‘Exercise and lose weight.’”

June has suffered chronic pain since puberty when their breasts developed faster than their spine. Doctors regularly told them exercise and weight loss would solve their back pain, advice that minimized the pain most exercise caused them.

“A therapist told me my mood would improve if I did more cardio,” June said. “I’m here because I want to die. You telling me to do more cardio isn’t going to help me want to die any less.’”

Weight stigma often stems from an idea that patients are at fault for their body size. Blaming people for their weight implies that long-term weight loss is attainable. However, a 2015 study that followed patients with obesity for nine years found sustained weight loss is unlikely for most people. Less than 1% of the patients reached “normal” weight and about 60% of those who lost weight gained it back.

“People can’t take weight off, that’s a known thing,” said Joshua Safer, an endocrinologist who’s the executive director of the Mount Sinai Center for Transgender Medicine and Surgery. He’s trying to create a pathway to bariatric surgery for patients seeking top surgery.

However, not everyone is interested in having bariatric surgery. It can be an onerous, long, and financially burdensome process that comes with its own complications and stigma. “To get a bariatric surgery evaluation is by itself another entire journey with the same amount of hurdles [as top surgery],” said Del Corral, the plastic surgeon.

Prescribing weight loss can also trigger disordered eating behavior, especially for trans people who are at two to four times higher risk for eating disorders than cisgender people. Eating disorder treatment is often steeped in anti-fat bias and there’s a dearth of trans-inclusive treatment options.

At this point, it’s hard to tell how the recent rise in popularity of weight-loss drugs like Ozempic and Wegovy will impact the surgical landscape. Multiple doctors who spoke with STAT said the stunning demand for the drugs could make weight stigma worse.

After his first surgeon denied him, Wescott spent months despairing that no doctor would operate on him. Then, an Instagram post featuring someone’s top surgery results caught his eye. “I saw a guy who was virtually indistinguishable from me,” he said. “I just burst into tears.”

He left a comment on that picture, “Wait a minute, you can actually do this? His body looks like mine, you can actually do this?” He immediately booked a consultation.

When his surgeon said, “I see no reason you’re not a perfect candidate for top surgery,” he cried on the Zoom call. “It was so overwhelming to have someone in the medical field look at me and go, ‘No, you’re not too big. This is definitely something we can help with.’” He booked a hotel room and he and his roommate drove down to Florida from North Carolina.

He had his surgery a week before his 31st birthday. Although top surgery is usually an outpatient procedure, his surgeon decided to keep him in the hospital overnight to make sure he recovered from the anesthetic, since fat patients are at greater risk for complications from anesthesia.

He developed an infection, but he blames that on driving the 12 hours back to North Carolina too soon. He accidentally pulled off some of the surgical glue, which opened up the wound and he didn’t realize that until he was home. He checked into the ER and was fine after an IV drip of antibiotics.

Now, Wescott loves his chest. “It has helped me so much in terms of confidence and getting back into being excited to meet people again and being intimate with people,” he said. “My scars are prominent, but I almost like it more that way. I did this, I made this decision.”

June however, couldn’t find a surgeon willing to operate on them who took their insurance. After months in a depressive cycle caused by their first consultation, they resigned themself to major weight loss. It took more than a year, but they dropped 60 pounds and had top surgery in August 2022.

“It’s nice to be able to actually walk with my chest held high,” they said.

However, their recovery has been challenging. They’re navigating the multiple hostilities they now face being perceived as a Black man and being visibly trans.

They’re frustrated with all they went through. They watched slim friends decide to have top surgery and get it, all while they were waiting. “I carried a lot of that resentment until the day I got surgery,” they said.

They’re channeling their frustration into being a resource for people in similar circumstances.

“We can’t continue to live in a world where my situation happens over and over, where that’s the expected norm,” they said. “It’s just not fair to anybody.”