Sean J Iwamoto

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.

While endocrinologists continue to initiate gender-affirming hormone therapy (GAHT) in healthy transgender and gender diverse (TGD) patients, they may also encounter more TGD patients in their clinics with complex medical histories that influence the patient-provider shared decision-making process for initiating or continuing GAHT. The purpose of this Approach to the Patient article is to describe management considerations in 2 adults with thromboembolic disease and 2 adults with low bone mineral density in the setting of feminizing and masculinizing GAHT.

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.