Patient-Centered Approaches to Using BMI to Evaluate Gender-Affirming Surgery Eligibility

Abstract

Body mass index (BMI) cutoffs are routinely used to assess eligibility for gender-affirming surgeries (GAS), yet they are not empirically based. The transgender population is disproportionately affected by overweight and obesity due to clinical and psychosocial influences on body size. Strict BMI requirements for GAS are likely to cause harm by delaying care or denying patients the benefits of GAS. A patient-centered approach to assessing GAS eligibility with respect to BMI would utilize reliable predictors of surgical outcomes specific to each gender-affirming surgery, include measures of body composition and body fat distribution rather than BMI alone, center on the patient's desired body size, and emphasize collaboration and support if the patient genuinely desires weight loss.The American Medical Association designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ available through the AMA Ed Hub TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity. Assessing EligibilityThe number of transgender patients seeking gender-affirming surgery (GAS) has dramatically increased in recent years. 1 Body mass index (BMI) cutoffs are routinely used to assess eligibility for GAS due to concerns about adverse surgical outcomes. 2,3,4 Results from the National Surgical Quality Improvement Program revealed that the effect of BMI on surgical outcomes presents the greatest risk to patients with morbid obesity (BMI ≥ 40). Commonly cited concerns include increased risk of surgical site infection; cardiovascular risks, such as cardiac arrest and myocardial infarction; and pulmonary complications, such as pneumonia, reintubation, and prolonged ventilator support. 5,6 Risks associated with delaying or denying access to GAS are also salient. Genderaffirming medical interventions, including hormone therapy (HT) and GAS, are associated with improved quality of life and decreased levels of anxiety, depression, gender dysphoria, and suicidal ideation. 7,8,9 The eighth version of the World Professional Association of Transgender Health guidelines characterize GAS as "medically necessary" for some patients to alleviate gender dysphoria. 10 Thus, surgeons must consider not only