A new study has found that body mass index, or BMI, has little association with serious complications after masculinizing top surgery, with researchers calling for the standard to be reevaluated and loosened when determining a patient’s eligibility.
Researchers at the Johns Hopkins Center for Transgender and Gender Expansive Health released the study in the journal Annals of Plastic Surgery on November 1. After reviewing more than 2,300 cases of chest masculinization surgery (CMS, commonly referred to within the community as “top surgery”) that were performed in the U.S. between 2012 and 2020, researchers found no correlation between a patient’s BMI — the ratio between their height and weight — and whether the person develops severe post-surgical complications, even though that measurement is frequently used to determine whether a surgery will be approved in the first place.
“Traditional BMI requirements related to top surgery have been highly surgeon specific, not standardized and only based on studies with small sample sizes,” lead study author Dr. Bashar Hassan wrote in a press release Tuesday.
Although some patients with BMIs in the “obese” and “extremely obese” ranges did report higher rates of minor complications like perioperative bleeding, researchers found no correlation between high BMI and major complications, such as renal failure or sepsis. The most significant correlation, according to the study, was between high BMI and risk of developing a urinary tract infection while in the hospital — which, the authors noted, could be due to more time spent wearing a catheter.
“Our results suggest that while increasing BMI is associated with the development of postoperative complications after CMS, the overall likelihood of life-threatening and significantly morbid complications is negligible,” the authors concluded, going on to recommend “re-evaluation of BMI cutoffs” for transmasculine patients. Researchers further noted that trans men with high BMIs generally have “greater degree of chest dysphoria and difficulty in performing chest binding,” making the loosening of BMI restrictions for top surgery even more important.
BMI as a concept was created in the 1800s by sociologist Adolphe Quetelet for use as part of his study of the “social ideal” of the “average man.” In other words, it was not developed as a tool of medical assessment, even though that’s how it is used today. While conventional medical wisdom has long held that high BMI leads to health problems, evidence proving so has been tough to pin down, and there are increasing calls by activists and professionals alike to reduce BMI’s influence on the medical field, or abolish the measure altogether. Some have cited BMI’s historical use as a tool for medical racism, while others point out that using it to exclude people from drug trials can be harmful because of the ensuing lack of information about correct dosages, potential side effects, and adverse reactions with other drugs.
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Dr. Fan Liang, a member of the Johns Hopkins department that conducted the study, told STAT News in June that while more complicated surgeries like phalloplasty are “less predictable,” surgeons should not use BMI to deny top surgery to trans men — who, according to another study in August, report high satisfaction and almost no regret following the procedure
“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,” Liang said.
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