What happens when access to a vital operation depends not only on medical need, but on a number on a BMI chart? This is the current predicament of 28-year-old M*, who is stuck in an agonising, years-long wait for top surgery. “With my first referral, the surgery was cancelled because I was over the BMI limit of 40,” they tell Dazed. “The surgeon kept me on the waiting list until I lost weight, but even when my BMI dropped below 40, they moved the goalpost to 35, and then 30.”

M sought out a different surgeon, one who “was supposed to have a better attitude towards people with higher BMIs”. After months of anticipation, they finally pencilled in a date. But on the operating table, they had a bad reaction to the anaesthesia. The surgeon promised to reschedule, but M later got a call saying that, because of the complications, they would need a BMI of below 30, which would have to be maintained for a minimum of six months, before they could undergo the operation. “Because of how long it would take, they discharged me. It’s been the worst experience of my life, and now surgery isn’t on the horizon at all.” The question is not whether surgery carries risk, or whether doctors should assess patients carefully. It is whether BMI, a blunt and increasingly contested measure, should be used as the determining threshold for care. 

Trans and gender non-conforming communities are at much higher risk of disordered eating. According to a study cited by leading eating disorder charity Beat, around 18 per cent of trans men and women have had an eating disorder at some point in their life, compared to 1.8 per cent of cis women and 0.2 per cent of cis men. The key question is: why?

The contentious weight limits on gender-affirming surgeries could offer one explanation. The World Professional Association for Transgender Health (WPATH) guidelines on gender-affirming care – the global gold standard – don’t specify a BMI requirement for surgeries. BMI, developed in 1832 by a Belgian mathematician who analysed groups of white, cis bodies to establish statistical definitions of the “normal man,” is increasingly seen as outdated and problematic. And yet, two centuries later, it’s still the benchmark for the NHS. If you’re a trans person seeking any number of gender-affirming surgeries, BMI limits tend to be less rigid if you pay for private care. If you go overseas, they’re often not a factor at all. Surgeons sometimes cite anaesthetic risk, equipment limits and clinical capacity when explaining BMI cut-offs. But for patients, the result is often the same: access to care becomes conditional on weight loss. For trans patients in the UK, the situation is simple: if you can afford a private surgeon who’ll accept a higher BMI, you can risk it. If not, the only option is to lose weight. When dysphoria clouds every moment of your life, you are likely to feel an urgent pressure to do so as quickly as possible.

18 per cent of trans men and women have had an eating disorder at some point in their life, compared to 1.8 per cent of cis women and 0.2 per cent of cis men.

Blake Knapp, the personal trainer behind the Transmasc Training App, recently worked with a client tasked with losing weight to access top surgery. Knapp knows firsthand how life-changing the procedure can be – he tells me it radically reshaped his relationship to his body – and so agreed to help. Knapp was already working with the client, who he describes as “happy in their fat body,” on using exercise to preserve their mental health and to build strength, rather than to lose weight. “But they needed the surgery, so we agreed to work together to jump through the hoop.”

Grey, a 30-year-old transmasculine person, had their top surgery options severely limited by their BMI. “I wanted a non-flat result to fit with my body better, but my surgeon erred on the side of leaving behind more than less, which still causes dysphoria around my chest,” they say. If Grey wants a revision, they either have to pay for expensive liposuction, lose weight, or opt for weight-loss drugs. “It feels painful to me that I had to make compromises in order to access the surgery at all and to still be experiencing dysphoria,” they say.

It isn’t just BMI limits for gender-affirming surgeries which complicate trans communities’ relationships to our bodies, but cultural assumptions around what certain bodies should look like. None of these pressures are unique to trans people: cis people are also taught to read fat, thinness, curves and muscle through gendered expectations. But for trans people, those pressures can become entangled with dysphoria, safety, passing and medical gatekeeping, which raises the stakes dramatically. Androgyny, for example, has long been seen as synonymous with thinness. As a fat, non-binary person myself, I used to pore over glossy editorials which hammered home the narrative that to be androgynous is to be waif-like, so slim that any legible trace of gender is whittled away. Meanwhile, curves, which are often associated with a feminine body, can bring up complicated feelings for trans men and transmascs. 

“My main reason for losing weight and staying active is to keep my dysphoria at bay,” says Harry Nicholas, author of A Trans Man Walks Into A Gay Bar. “If I gain weight, it adds curves to my hips and glutes, which are where I feel dysphoria most strongly.” Marley, a 41-year-old non-binary parent, concurs: “Weight gain can trigger a downward spiral, even if my clothes still fit perfectly.” After Marley had top surgery, their feelings of dysphoria then zeroed in on their hips. “I guess my brain was busy processing dysphoria in a different area of my body.” Other trans people I speak with share similar struggles: one wanted desperately to lose weight to shrink their breasts before they got top surgery; another says that their weight impacts their sense of identity so much that they’re almost at the point of viewing weight-loss drugs, however uneasily, as gender-affirming interventions.

“I experienced disordered eating my whole life. Before I understood myself as trans, I knew I was using these behaviours to transform my body into something that felt more like me” – Grey

Access to hormone therapy can hugely alleviate dysphoria tied to our body shape, partly because hormones can radically change fat distribution. But a combination of years-long waiting lists and high private healthcare fees mean that many of us are denied it, or pushed towards the riskier prospect of DIY self-medication. Especially without hormones, weight gain – depending on where we gain it – can severely impact our mental health.

“I experienced disordered eating my whole life,” says Grey. “Before I understood myself as trans, I knew I was using these behaviours to transform my body into something that felt more like me.” The strange paradox of disordered eating is that the effects of deeply unhealthy behaviours are often praised. “Everyone was congratulating me and saying how great I looked. But now, as a fat, hairy trans person who is read as a ‘failed woman,’ I feel like I’ve become everything that society despises. I’m often made to feel like a monster. Sometimes it makes me feel like I’m the worst thing people can imagine themselves being, and that impacts how I see myself, and whether I’m able to feel desirable or not.”

For trans women, the struggles are similar. “My body never feels feminine enough,” says Christina-Jae Angel, who writes poetry about her life experiences. “I’ve been anorexic since 2015, and I’ll always say that I’m in recovery, not that I’ve recovered. I always feel like it could come back.” Angel says she feels additional pressure as a trans woman of colour, not only to match society’s punishingly high standards of hyperfemininity, but also to ‘pass’ as cisgender for safety and protection. Angel is working with limited resources: “we don’t all have the budget, the funds, the connections, to be able to have these surgeries,” she explains. “It’s bad enough to see [extreme procedures like] rib removals and rib-breaking becoming a trend again, and then you have to deal with the likes of Ozempic as well.”

In today’s world, the policing of trans bodies is exhausting. Some researchers are calling for the revision of BMI limits on gender-affirming surgeries, but there are other pressures to consider: the cultural obsession with thinness, the rising tide of anti-trans bills, the all-consuming nature of gender dysphoria. “I’ve actually put a lot of effort into repairing my relationship with my body and accepting myself as fat,” says M. “Wider society has been horrible, but I’m lucky to have a great support system and a partner who loves my fat body.” In a world that already pressures trans people to make ourselves smaller, smoother and more legible, being told that care depends on weight loss can feel all too familiar. M’s refusal to hate their body, after everything they’ve been through, is both radical and a form of survival.

If you’re worried about your own or someone else’s health, you can contact Beat, the UK’s eating disorder charity, or LGBT Switchboard for gender dysphoria.