In the progressive narrative surrounding Transgender healthcare, significant strides seem to have been made toward inclusivity and access. However, a critical barrier remains entrenched in the system, disproportionately impacting the most marginalized within the Transgender and gender-nonconforming (TGNC) community: the reliance on body mass index (BMI) as a qualifier for surgery.

In Washington State, a glaring disparity exists between those with private or employer-provided insurance and those on state-funded programs like Medicaid or Medicare. Patients with private insurance are more likely to find surgical providers willing to perform gender-affirming surgeries on people with a BMI over 35. In contrast, those relying on state insurance face significant hurdles, not only in finding providers who accept their insurance but also in meeting restrictive BMI thresholds that many surgeons and healthcare facilities impose.

This disparity underscores a critical flaw in our healthcare system: while access to gender-affirming care has ostensibly expanded, it remains inaccessible to those who do not meet arbitrary health metrics such as BMI. This measure, long debunked as a valid indicator of health or surgical risk, continues to gate-keep essential, lifesaving care. The persistence of BMI as a criterion starkly illustrates how deeply ingrained misconceptions about weight and health can influence medical practice, to the detriment of those it serves.

The lack of advocacy and legislative attention to this issue in Washington is troubling. The state's Transgender healthcare advocates and lawmakers have not yet recognized the importance of BMI-related barriers in discussions about healthcare access for TGNC people. Despite increased access to gender-affirming care for some, many of us must meet unrealistic body weight standards, which can drive harmful behaviors like eating disorders, just to receive treatment. This not only undermines the advancements made but also highlights the inequities that persist within the system, even in advocacy and organizing spaces.

Fatmisia - systemic discrimination against fat people - remains pervasive, and unchallenged not just in broader societal contexts but deeply embedded within LGBTQIIA+ and healthcare spaces. This discrimination often commodifies fatness when it is a source of Queer entertainment yet also paints it as a moral failure outside of that context, questioning people's ability to manage their health based on their weight. However, the factors contributing to a person's weight are complex and multifaceted, ranging from genetics to the very stress of experiencing marginalization.

Studies have shown that belonging to marginalized groups and facing systemic oppression can adversely affect health, leading to higher rates of obesity and eating disorders among TGNC people. This is particularly acute for those with intersecting identities of race, disability, and socioeconomic hardship. In the face of such challenges, the continued use of BMI as a gatekeeping tool is not only scientifically unsupported but also ethically questionable.

The disparity in care based on BMI in Washington serves as a stark reminder that our healthcare systems still harbor biases that need to be addressed. It's time for the state's healthcare advocates and legislative bodies to prioritize the needs of all TGNC people, regardless of their body size. Medical institutions and providers must reevaluate their practices and biases, ensuring they do not perpetuate harm but rather support the health, needs, and dignity of every patient.

This call to action is not just about healthcare access; it's about recognizing and affirming the humanity of fat TGNC people, ensuring they receive the care they deserve without bias or discrimination. Washington has made strides, but the journey toward true inclusivity and equity in healthcare is far from complete.

Mattie Mooney is a Trans health educator.