Approach to the Patient Navigating Body Mass Index Requirements for Gender-Affirming Surgery.

Body mass index (BMI) requirements for gender-affirming surgeries (GAS) present an obstacle to gender transition for many transgender and gender diverse (TGD) people. Furthermore, TGD people have unique barriers and preferences in managing their weight that must be considered. TGD patients frequently present to their endocrinologists for individualized, gender-affirming support to meet BMI cutoffs for GAS. This Approach to the Patient article combines expertise from several disciplines, including gender-affirming hormone management, weight management, mental health, gynecology, and plastic surgery. Multidisciplinary management considerations are offered for clinicians to assist TGD patients with obesity navigate BMI requirements to access GAS.

Filling a gap in care: addressing obesity in transgender and gender diverse patients.

Transgender and gender diverse (TGD) adults are more likely to have obesity compared to cisgender peers. Based on surveys, the TGD population experiences disparities in healthy lifestyle behaviors (e.g., physical activity, screen time) compared to reference groups. They also face significant socioeconomic and healthcare barriers to accessing affirming care and gender minority stress, potentially contributing to increased weight. Gender-affirming hormone therapy is associated with changes in body composition and increased weight, which may impact cardiometabolic risk trajectory. Obesity can also be a barrier to gender-affirming surgeries, and affirming weight management services tailored to TGD patients are an important gap in healthcare to address. This Perspective briefly reviews current literature on the unique barriers experienced by TGD people and their identified needs regarding weight management interventions. It also suggests areas for future research to best fill this gap in healthcare and research while supporting the provision of lifesaving gender-affirming care.

Meeting the Body Mass Index Requirement for Gender-affirming Surgery Using Antiobesity Medication.

One-fourth of transgender and gender diverse (TGD) patients presenting for initial gender-affirming surgery (GAS) consult is denied surgery due to obesity. Many surgery centers enforce body mass index (BMI) requirements for GAS because of concerns about perioperative risks, cosmetic outcomes, and reoperation. TGD people experience gender minority stress and disparities in lifestyle factors that likely contribute to excess weight gain. Gender-affirming hormone therapy has also been associated with increased body weight. Effective and affirming weight management interventions for TGD patients with overweight and obesity are currently lacking. We report the case of a 40-year-old transgender woman with a BMI of 39.6 kg/m2 who presented for weight loss to qualify for gender-affirming bilateral breast augmentation, requiring BMI <35 kg/m2. In addition to lifestyle modification counseling, she was started on semaglutide with monthly dose escalation, leading to 13.9% weight loss with a BMI of 34.1 kg/m2 within 3 months. This case highlights the need for access to affirming weight management services for TGD patients pursuing GAS and the role of antiobesity medications in reaching presurgical BMI targets. Further studies should evaluate the needs of TGD patients in weight loss interventions and the effects of weight loss and antiobesity medications on gender-affirming hormone therapy.