TW: This piece discusses anti-fat bias, anti-trans bias, suicidal ideation, violence against trans people, and contains really, really sad interviews with trans people that might just make you super sad, okay? This is a trigger warning.

Translation: La intersección de la gordofobia y la transfobia

Is body positivity making enough space for fat transgender people? Some would say no, as the specific barriers to transition that fat trans people face are rarely spoken of in body positive spaces. What are those barriers, how have we failed to address them, and how can we address them in the future?

Johnny describes his experience with a plastic surgeon in Denver, Colorado as leaving him “humiliated.” The trauma of being denied his top surgery left him dissociative and nearly out of a job. A few weeks later, a different doctor gave Johnny the all-clear for surgery. So what was his first surgeon’s reason to deny him something so obviously important?

“I was ‘overweight and would look weird after surgery if my stomach was bigger than my chest.’ Doctor’s words.” Johnny, a thoughtful trans man who was kind enough to answer my questions, continues, “it seems like a very thinly veiled ‘you won’t be attractive enough for us to proudly call you our patient.’”

Fat transgender people face significant barriers to medical transition, including HRT and GRS, often in the form of surgeons who refuse to work on them, or doctors who feel they won’t make “proper” men and women. For this reason, transgender people have the highest rates of eating disorders, even higher than cishet women, yet another life-threatening danger.

In their essay No Apology: Shared Struggles in Fat and Transgender Law, Dylan Vade and Sondra Solovay explain how fat and transgender people are coerced by the legal system to assimilate to cisnormative standards: “When attempting to overcome these barriers by using the legal system, not only are fat and transgender people expected to share a goal of assimilation, but they are coerced into reinforcing fat-phobic and transgender-phobic norms in to secure basic legal rights enjoyed by their non-fat and non-transgender peers. This is a cruel cycle: oppression necessitates the legal intervention, yet the person must participate in that very oppression to receive legal protection.” They go on to explain, “Winning cases generally adopt a legal posture that reinforces societal prejudices. Cases that challenge societal prejudices generally lose.” They illustrate this with two cases of fat discrimination in California, John R. of Berkeley and Toni C. of Santa Cruz.

Both were seeking damages for weight related discrimination in the workplace. John R., who talked about his fatness like it was a problem he could not cure, won his case. Toni C., who was unapologetic about her fatness, did not. Toni rejected a medicalized view of her fatness, and her argument was entirely unapologetic. Refusing to locate the problem on her own body, locating it instead in a fat hating society, Toni lost her case.

Though Solovay and Vade are discussing the legal system and not the medical system, after interviewing several trans people who have had their HRT or GRS denied to them due to their weight, the similarities are startling. Many see trans people of all genders as challenges to the gender binary. When they are unapologetic about their gender and bodies, they are seen as threats. When they are fat, many surgeons and doctors read their gender as too deviant, and even iconoclastic, and they can (and do) demand weight loss before they’ll prescribe hormones or agree to surgery. But with a 90–95% failure rate of diets and trans adults having a 40% rate of attempting suicide, are these expectations of weight loss doing more harm than good?

Many would assume that if doctors are denying trans people HRT or GRS due to their weight, there must be a solid medical reason but the interviews I conducted seem to suggest quite the opposite. One respondent described their doctor saying Adele, the singer, was too big to be a ‘real woman’ and that if she dressed androgynously, people would “think she was here to fix the roads.” Others describe clinics with tests to ascertain if their gender is “true” to not, including patronizing questions about whether trans men enjoy mechanic magazines. Heteronormativity was also a theme, with bisexual trans people reporting their doctors tried to leverage their sexual orientation against them to talk them out of transition. Many were told by one surgeon they would need to lose weight, only to be told by another that they wouldn’t, thus begging the lie that doctors can’t do these surgeries on fat people. Most report little to no emotional support from physicians after a weight-based barrier is placed before them, many saying that instead they were prescribed diet pills. All report periods of high distress, most with suicidal ideation or attempts, following their denials.

Erin, of Melbourne, Australia, provides insight into how fatmisic, or anti-fat, attitudes can harm for life. Erin, a bright trans man in his early thirties, began seeking medical transition at 19. He describes a clinic he still fears retaliation from and cannot publicly name. His gender was questioned both in relation to his bisexuality and to his disability. He was told that he should wait to transition until he “picked” a sexuality or until he got “better” from his lifelong incurable illness. Erin was also told he could not continue in the program and receive HRT unless he lost weight.

“When I asked how I was supposed to lose weight considering I am unable to exercise due to my disability, I was told ‘there are pills you can take for that,’ and was sent to a doctor.” Erin was put on phentermine, an amphetamine frequently prescribed for weight loss and notoriously dangerous.

“It gave me heart issues (tachycardia), it made it impossible to sleep, it made me jittery, and it made me feel unwell.” Though he wanted to stop taking the drug, he was reminded unless he lost weight, he could not continue in the program. As there was no other program available in his area, “I felt like I had no option, so I kept taking it for a few more months. I got sicker. My heart rate kept climbing, I kept not sleeping, and I began experiencing terrible anxiety. I also, incidentally, did not lose any weight during this time.”

Erin describes long periods of feeling intensely suicidal both in the program and after leaving it. Even though he has since gotten his HRT and an affirming GP through a different doctor in a different city, Erin says, “I feel like there’s two versions of me. There’s the me that I am, and there’s an alternate reality out there where I was given access to the treatment I needed when I first sought it, and I imagine that version of me is a much happier, healthier, and well adjusted person than I am.”

Juanita, a trans woman, writes beautifully and heartbreakingly of her experience at Steve Biko Academic Hospital with the medical panel when it came to the decision on whether she would get her hormones or not:

Dr Martin informed him that the only issue was my blood pressure, but that I was in good health and he recommended I start hormone treatment immediately. I was so delighted to hear those words, but Prof Lindique smashed my excitement. “I don’t agree.” There was silence as the Prof suddenly focused on me. “What do you weigh?” Uncomfortably I replied. “You need to lose at least 25 kg’s before we would operate on you.” I was sitting there confused while listening to Prof Lindique and doctors from the Endocrine department arguing. “This is ultimately my decision. Dr Khosa, are you comfortable to operate on an obese patient.” Dr Khosa confirmed that I needed to lose weight. Prof Lindique went on: “I feel it is unnecessary that we place the patient on hormones now. Why do we need to place her on blockers when removing the testis will be more beneficial and cost-effective. We can hopefully do the surgery in six months.” Dr Martin tried one last time to convince Prof Lindique before my fate was sealed. I left the room with tears about to burst out of my eyes. The moment I saw JL, I collapsed in her arms crying hysterically.

Juanita describes her cis friends as not understanding the severity of the decision, while her trans friends recognized this could mean living dysphorically for years without solid, proven treatment. Here we see how one doctor’s fatmisia was enough to upend Juanita’s transition and put her in a dangerously fragile emotional state. Considering the threat trans people face for not “passing”, not just from violent strangers but from landlords refusing to rent to them, employers refusing to hire them, judges ruling against them, and the cruel and casual violence of misgendering, the trauma of being denied hormones is understandably beyond demoralizing, it is dangerous. Given that these doctors often rely on widely discredited science, like body mass index, and are rarely providing support to surpass this barrier, trans people are often left to deal with an unfair prognosis on their own. Amy Tysoe relates that her doctors told her that her HRT would be withheld until her BMI was below 35, surgery below 30, and then her doctor could not or would not even do the reverse calculation to give her a target weight.

Given this information, why is body positivity (with a respectful nod to Shay Neary, the incredible plus size transgender model) so overwhelmingly cisgendered?

In writing about Oscar Zeta Acosta’s autobiography, Marcia Chamberlain provides some insight into ways the fat positive movement has failed people of color. “The movement, which made it clear during the 1970s that it was concerned with only one issue, implicitly demanded that he leave his skin color at the door.” She goes on to add, “But ranking oppressions created tough situations for people like Acosta whose ‘stigmas’ could not be neatly separated out and judged on a scale of one to ten. It is interesting to note that just as fat people were absent from positions of leadership within the Chicano movement, so too the converse was true: most spokespersons for fat power during the 1970s were white.” I would posit that, while the problems of race are still prevalent in the fat positive community, we must also contend with problems of gender and presentation. How do we treat the fat trans people among us? When we speak of body positivity and fat positivity, do we include the needs of fat trans men, fat nonbinary people, and fat trans women? Do we focus on needs that they specifically have, or do we only focus on the needs that affect “all” of us?

Shay Neary, in discussing another point of contention for fat and trans women, points out, “Also, why do trans women get booked [for shoots] and then put in suits? [The industry] always wants trans women to look a little bit masculine, because that’s somehow more high fashion. If you’re not androgynous, if you’re too feminine or masculine, they don’t want to book you. They want people to know you’re trans, so they can include it in press releases and so on and so forth. It ends up exploiting my identity to make the designer look better.”

With this in mind, how do we approach issues of trans identity as cis fat activists without exploiting them? I believe the best way to do this is to uplift their voices, and also to focus, as activists, on issues that specifically affect fat trans people alone, like the denial of GRS due to weight. When we discuss how fat is feminizing on men, we must contend with how this specifically harms trans masculine people. When we discuss how fat is ungendering on women, we must grapple with the real and serious danger this places trans women in from cis violence.

We must also understand the realities of fat for the trans body by listening to fat trans people. S. Bear Bergman writes in Part-Time Fatso: “Ironically, it’s my fat for which I am sometimes most grateful when I want the world to see me as a man. My large frame and relative ease moving through the world in it are transgressive and unusual for women raised in this culture. I have a long stride, I hold my head up, and these factors alone sometimes tip the scales of perception over into the man category. My girth and breadth allow my smallish breasts to be read as ‘fat boy tits,’ and my broad-featured Ashkenazi face to look commanding and masculine instead of balabusta-with-a-head-cold. My fat kid inability to sit with my legs crossed at the knee, and all the problems it caused during the years in which I was still being poured into dresses and skirts, created — through the miracle of adolescent rebellion — a lifetime habit of sitting with my legs crossed ankle over knee in the traditionally masculine, trouser-wearing style.”

However, where Bergman finds his fatness affirming of his gender, many others, including Katelyn Burns, do not. In her beautiful piece, Burns describes how fatmisia discouraged her from transitioning: “Forrest’s words were an analog for my internal dialogue: ‘you’re too fat, you’re too tall, you’re too bald to be a woman.’” Given how trans people are so often denied access to medical transition, one can’t be surprised by Burns’ fear. When your very life is dependent on the approval of others you are not left with a “choice” but rather with an insurmountable wall that you must climb or die. For many, the climb is simply too great.

Indeed, many trans people express considerable discouragement when discussing their weight and medical transition. According to Erica, she hasn’t pursued GRS because she knows she’d be asked to lose 90lbs for it, a hurdle she finds unmanageable with her depression. “It’s not even really a choice I can make. Skipping a single meal can make me a useless lump just lying in bed.” Her sentiments echo Erin’s, whose disability left him no choice but phentermine and a lifetime of illness from its side effects or the suicidal risk of dysphoria.

Can we even call that a choice?

This is a subject I as a cis fat activist have struggled with in the past. We must recognize the terrible pressure trans people are under to lose weight, and we must relieve that pressure. Statistics show that diets simply do not work, and that dieting to lose weight discourages the dieter and makes it more likely that they will gain more weight. There’s nothing wrong with being fat but there’s definitely something terrifying about being dysphoric and untreated because of your body.

Unfortunately, fat trans people may find legal recourse under the ADA difficult to find. In the Sixth Circuit, it’s been decided that a fat person does not qualify as disabled without proving that an underlying disability is causing the weight. In other words, it doesn’t matter how heavy you are, or if that heaviness impairs your mobility, in the Sixth Circuit, if you can’t prove where your fatness comes from, you are not disabled. Setting aside the egregious treatment of fat disabled people in this regard, it also closes one of the few available routes to legal recourse for trans people.

Fat positivity and body positivity stand at a crossroads where they must decide if they will continue to be white and cis and abled focused, or if they will embrace liberation for all. Who do we hear in fat positive circles? Which voices do we lift up? And why?

As we continue to make our spaces more inclusive, we must remember the reason we are doing it. Not for the brownie points. Not to be congratulated for deigning to include fat trans people, disabled people, and people of color. Rather because we are all trapped upon a perilous machine that steals our worth at birth and segments us into hierarchies of bodies, and until all of us are free, until the most marginalized among us are free, none of us will be free.

This is normally where I put my tip jars, but if you enjoyed this piece, I suggest a donation to one of the people on twitter’s #TransCrowdFund or a donation to the Trans Lifeline instead.