Stop using body mass index as qualifier for gender-affirming surgery, advocate says

A trans advocate in Halifax is calling for doctors and surgeons in Nova Scotia to stop using body mass index as an indicator of someone's health.

Felix Vandergrift says the index, known as BMI, is discriminatory and is yet another barrier standing between trans individuals and life-changing gender-affirming surgeries.

"The fact that I wasn't even able to book a consult because my BMI was too high is unacceptable. Period," said Vandergrift, who was recently denied a consultation to get a double mastectomy due to his weight. "You don't know anything about me, and you're telling me my BMI is too high."

Vandergrift said he was told by the staff at a private clinic in Halifax that he would have to lose weight and have a BMI under 30 in order to be seen by the doctor for a surgery consultation.

BMI is a measurement of body size that takes a person's weight in kilograms, then divides it by the square of the person's height in metres. For example, an adult who weighs 70 kilograms and whose height is 1.75 metres will have a BMI of 22.9. 

Depending on where a person's BMI lands, they could be classified as underweight (BMI less than 18.5), normal weight (BMI 18.5 to 24.9); overweight (BMI 25 to 29.9) or obese (BMI 30 and over).

Vandergrift pleaded with the staff, pointing to a 2019 settlement in which the Department of Health agreed to remove a BMI requirement for breast reduction surgery following a human rights complaint by Halifax woman Melody Harding. It still didn't get him the consultation.

After being met with a hard no, Vandergrift left the office angry and couldn't help thinking about others who may be going through something similar.

"I can't imagine a young queer person who is already uncomfortable in their body, thinking there's no way I can ever change this, because my BMI is too high."

Vandergrift says the concept of BMI is outdated, and he's not the only one that feels that way.

Michael Vallis, a registered health psychologist specializing in obesity, diabetes, cardiovascular risk and gastroenterology, says doctors across the country still use BMI. While he said that being obese may put someone at a higher risk of complications before or during surgery, BMI alone is not a measure of health

"Everybody talks about BMI and it's being used as an indicator of health, and I think what's happened is that the science of obesity has really caught up to us," said Vallis. 

"It's not about your body weight. It's about how much adipose tissue, or how many fat cells, do you have. And where are they? And so all of a sudden BMI becomes a much more imprecise measure."

Grabbing the scale

Vallis says for some procedures, such as weight-loss surgery, a person can't be safely operated on if they are over a certain size. In those cases, there would need to be other interventions to lower their weight.

"That's a very, very defendable position if physicians can really describe the reasons why a surgical procedure would be too risky. But apart from that, I think it's just too easy for people to grab the scale and then they simply kind of put all the blame on the person."

Dr. Richard Bendor-Samuel, the director of Landings Surgical Centre where Vandergrift unsuccessfully sought his surgery, says the facility is gender-inclusive. He says they do not operate on "higher risk" patients.

"As such we limit liability and value safety first. Extremes in BMI (high or low) are best managed in a hospital setting which has the equipment and manpower to manage these patient groups," Bendor-Samuel said in an email.

"Many studies show that high BMI is often — but not always correlate with a variety of health conditions such as diabetes, high blood pressure, heart disease, liver problems, breathing problems, as well as a number of different types of cancers, among other conditions that increase outpatient surgical risks."

Vallis says focusing on BMI perpetuates bias and stigma toward those with higher weights or considered "obese" by BMI standards. 

Vallis also works with Obesity Canada, a registered charity for health professionals, researchers, policymakers and Canadians living with obesity.

He says they're promoting a different approach to health-care providers called the Edmonton obesity staging system. This approach looks at things like body weight as well as other medical comorbidities such as heart health, kidney function and even self-esteem.

"We would categorize people in terms of how medically or functionally impaired they are and then treatments would be designed to address that," said Vallis.

Nova Scotia Health Minister Michelle Thompson told reporters at the legislature last week that BMI is part of a holistic assessment, and is not the only deciding factor that would go into whether a surgery would proceed.

Doctors Nova Scotia told CBC News in an email that while there is no official rule saying doctors in the province must use BMI as a prerequisite to performing surgeries, they are permitted to use it at their own discretion.

Act to be reviewed

Thompson said the province plans to review the Gender Affirming Care Act again soon, and the use of BMI as a qualifier for gender-affirming surgeries could be raised as one of the barriers.

"I would say that we will continue to hear from people directly and understand how the current policy impacts their ability to access care, and see where we can adapt and implement things that would make it easier, but always looking at safety and quality of the care we provide," she said.

Nova Scotia Health spokesperson Brendan Elliott said in an email there are five plastic surgeons in Halifax doing gender-affirming surgeries, "so there is no risk that someone will go without care."

For now, Vandergrift says he's going to keep advocating for the removal of BMI and talk to anyone who will listen.

"This is just my personal nightmare of going through, but I know I'm not alone."