[Skip to Content]
[Skip to Content Landing]

Should BMI Help Determine Gender-Affirming Surgery Candidacy?

Learning Objectives
1. Explain a new or unfamiliar viewpoint on a topic of ethical or professional conduct
2. Evaluate the usefulness of this information for health care practice, teaching, or conduct
3. Decide whether and when to apply the new information to health care practice, teaching, or conduct
1 Credit CME

Use of body mass index (BMI) as a health care metric is controversial, especially in candidacy assessments for gender-affirming surgery. When considering experiences of fat trans individuals, it is important to advocate for equitable divisions of responsibility for and recognition of systemic fat phobia. This commentary on a case suggests strategies for increasing equitable access to safe surgery for all body types. If surgeons use BMI thresholds, simultaneous effort must be made to advocate for data collection so that surgical candidacy criteria are evidence-based and equitably applied.


ZZ is a trans man and a patient of Dr S, a surgeon at a clinic offering gender-affirming services, including hormone therapy, chest surgeries, and genital surgeries. During 5 years of hormone treatment, ZZ's weight increased to a point at which he now has a BMI of 35, which is clinically considered class II obesity.1 As a result, he does not qualify for most gender-affirming surgeries (GAS) offered by Dr S at the clinic. ZZ is distressed and asks, “What was the point of hormone therapy if all it did was make me so fat I can't get surgery?”

Dr S considers how to respond.


Transgender, nonbinary, and other non-cisgender (henceforth referred to as trans) individuals with a body mass index (BMI) of at least 30 (referred to clinically as “obesity”),1 could be denied access to GAS2 due to systemic bias and social inequity. Quiz Ref IDHigh BMI is associated with conditions such as sleep apnea,35 type 2 diabetes, gallbladder disease, and certain types of cancers.6 It is also associated with perioperative issues, including surgical site infection,7 increased operative time,8 and greater technical difficulty when operating9,10 and hence is often a primary factor in GAS candidacy.9 However, this risk metric can obscure other multifactorial causes1113 that contribute to poor surgical outcomes.79,14 Moreover, some consider BMI thresholds to be a manifestation of weight stigma,9,11 or the negative stereotyping of and discrimination against fat individuals.12,15 (We use the word fat here as a neutral descriptor of body size in alignment with fat activists to help destigmatize the word.16) Weight stigma, among other biases, can cause clinicians to erroneously attribute a patient's health issues to their body size.12 As a result of weight stigma, fat patients may be inclined to avoid clinical care.12

Equitable treatment requires that we consider the current surgical risks for fat patients, how weight stigma contributes to these risks,12 and the appropriate uses of BMI in clinical care. It is also important to acknowledge the problematic history of BMI, including the lack of validation for its use in non-cisgender populations of color11 and the relationship between weight stigma and racism.17,18 For example, among Black men, experience of major discrimination is associated with obesity.19

Here, we discuss weight stigma, inadequate empirical evidence of GAS risks associated with BMI, and how to reduce barriers to GAS for fat trans people like ZZ by addressing structural oppression. In the absence of definitive evidence of a direct causal link between high BMI and poor GAS outcomes, we propose a more holistic approach to surgical candidacy that includes shared decision making, wherein BMI is not used as the sole determinant of GAS access but is considered alongside weight stigma and factors like procedure type and body composition.

Weight Stigma

Quiz Ref IDZZ's weight and his perception of how it affects his surgery access is mediated by internalized weight stigma. Internalized weight stigma poses concrete risks to patients by negatively influencing eating and exercise behavior,20 and it is also associated with depression and body shame.20 Even if ZZ ends up having surgery, he may struggle to find peer support, the benefits of which for surgery and medical care have been described in the existing literature for fat trans people who do not have easy access to GAS.20,21

Fat patients may also experience a lower quality of care due to clinician biases.12 Surgical teams can limit reinforcing these biases in clinical environments by questioning their own anti-fat attitudes, as well as by educating clinicians and staff members on the complexity of weight and weight change.12 Quality of care can be improved by using motivational interviewing and patient-centered communication12 and by shifting the focus from weight loss to the benefits of behavior changes, such as increased physical activity.12

Known and Anticipated Risks and Benefits

The benefits of GAS, including decreased gender incongruence, improved quality of life, and decreased suicide risk, cannot be understated.11,21 These data help make the case for proceeding with surgery despite potential risks associated with an elevated BMI.

Existing data on GAS indicate that the risk of complications is contingent on multiple factors, including procedure type, BMI, and body composition. Two studies have reported that gender-affirming mastectomy for patients with a BMI of 30 to 39.9 is relatively safe.22,23 Data on complication risk specific to genital GAS, however, is lacking9,11 and, with few exceptions,24 is not available for those above a BMI of 30 (see Tables 1 and 2).

Table 1. Stratifying Complications in Gender-Affirming Mastectomies, Including for People With a Body Mass Index of at Least 30

Common complications reported, No. (%)
Author, yMax BMIBMI, NHematomaSeromaInfectionSWDTotalConclusions
Berry (2012)NRAll, 1006 (6.0)NR3 (3.0)NR11 (11.0)No conclusions stated regarding BMI.
Frederick (2017)41.3All, 888 (9.1)NR0 (0)0 (0)29 (33)Mastectomy weight not associated with hematoma.
≥ 30, NRNRNR0 (0)0 (0)NR
Donato (2017)NRAll, 13018 (13.8)9 (6.9)NRNR32 (24.6)No association found between BMI and incidence of hematoma or need for revision.
≥ 30, 417 (5.4)NRNRNR12 (9.2)
McEvenue (2017)NRAll, 67944 (6.5)44 (6.5)25 (3.7)3 (0.4)123 (8.1)There was a statistically significant association between BMI and surgical technique (keyhole vs double incision with free nipple graft).
Kääriäinen (2017)NRAll, 5714 (24.6)4 (7.0)2 (3.5)NR19 (33.3)There was a statistically significant association between BMI and surgical technique (concentric circular incision vs transverse incision).
van de Grift (2017)35All, 5416 (29.6)12 (22.2)2 (3.7)7 (13.0)48 (NA)No conclusions stated regarding BMI.
Knox (2017)40All, 10112 (11.9)NR11 (10.9)21 (20.8)36 (35.6)BMI is a predictor variable for procedure type: patients with a BMI > 27 should undergo free nipple graft technique.
Gallagher (2019)57All, 1531 (0.7)0 (0)7 (4.6)3 (2)11 (7.2)All complications in patients with BMI ≥ 30.
≥ 30, 831 (0.7)0 (0)7 (4.6)3 (2)11 (7.2)
Watanabe (2019)NRAll, 35815 (4.2)NRNRNRNRNo significant association between hematoma formation and BMI.
Stein (2020)≥ 40aAll, 971 (1.0)2 (2.1)4 (4.1)3 (3.1)18 (18.6)Difference between complication rates for patients with BMI < 30 and BMI ≥ 30 was not significant. Difference in rates of minor wound dehiscence was significant for patients BMI < 30 vs BMI ≥ 30. No patient required operative revision.
≥ 30, 431 (1.0)2 (2.1)1 (1.0)3 (3.1)14 (14.4)
Pittelkow (2020)NRAll, 1451 (0.7)0 (0)7 (4.8)NR10 (6.9)Postoperative infection rates increased significantly between the "normal" and the "morbidly obese" and "super obese" groups but not between the normal and "obese" groups.
≥ 30, 791 (0.7)0 (0)6 (4.1)NR9 (6.2)
Rothenberg (2021)≥ 50aAll, 94844 (4.6)16 (1.7)20 (2.1)NR89 (9.4)BMI ≥ 25 did not have significantly higher odds of complications. No association between BMI category and need for revision.
Naides (2021)46.8All, 724 (5.6)3 (4.2)1 (1.4)1 (1.4)NRAuthors do not recommend a BMI threshold for patients undergoing mastectomy.
Rifkin (2022)NRAll, 48625 (5.1)174 (35.8)6 (1.2)NR205 (42.2)BMI independently predicted surgical site infection.
Table 2. Stratifying Complications in Other Gender-Affirming Surgeries, Including for People With a Body Mass Index of at Least 30

Author, yMax BMIBMI, NCommon complications reported, No. (%)
VaginoplastyVaginal fistula or woundcInfectionSWDTotalConclusions
Gaither (2018)NRAll, 3306 (1.8)NR17 (5.2)95 (28.8)BMI did not independently predict wound complications, fistula formation, or vaginal stenosis.
Ives (2019)48.2All, 1014 (4)1 (1)29 (28.7)53 (52.5)BMI did not predict major, minor, or any complications or urethroplasty.
≥ 30, 27NRNRNRNR
PhalloplastyUrethral complicationsPartial or total flap necrosis/lossSWDTotalConclusions
Ascha (2017)NRAll, 21357 (26.8)10 (4.7)9 (4.2)75 (35.2)Patients with BMI > 30 were advised to undergo RFF phalloplasty due to amount of subdermal fat on thigh.
Wirthmann (2018)44.1aAll, 3219.7 (8.6)b9 (3.9)39 (17)NRBMI > 25 showed a linear increase in complications but was not statistically significant.
≥ 30, NRNR1 (0.4)NRNR
Watanabe (2021)31All, 3219 (59.4)1 (3.1)NR28 (88)Recommend BMI and radiographic imaging be considered in decision making regarding donor flap choice.
Spennato (2022)37.5All, 45Fistula: 39 (86.7)Stricture: 19 (42.2)12 (26.7)10 (22.2)43 (96.0)No association was found between body weight and postoperative complications.
MetoidioplastyUrethral complicationsInfectionSWDTotalConclusions
Bordas (2021)32.8All, 81386 (10.6)NRNR207 (25.5)All patients, including those with a high BMI, were able to stand to urinate postoperatively.

Quiz Ref IDIn this data's absence we can extrapolate from similar procedures.9 For example, in robot-assisted laparoscopic radical prostatectomy, BMI correlates with pelvic visceral fat volume, pelvic width, and working space.43 More pelvic visceral fat can increase operative time and incidence of complications.43 However, in colorectal surgery, BMI appears to be less accurate at predicting the amount of visceral fat.44 Overall body composition therefore may be more helpful when estimating surgical risk, as BMI does not account for the effects of body composition on surgical outcomes. Reporting on surgical complications is also not standardized (see Tables 1 and 2).

Complications stratified by BMI provide more specific information on potential risks and outcomes, although only the studies by Stein et al34 and Gallagher et al32 analyze the data in this way. For gender-affirming mastectomy, a BMI of 30 or more is associated with hematoma,22,23,32,34 seroma,22,34,45 infection,22,32,34,36 and wound dehiscence.32,34,36 For phalloplasty, one study found no statistically significant relationship between a BMI of at least 25 and increased complications,25 although results may vary with type of reconstruction. In another study, one patient with a BMI of 44.1 experienced total flap loss and underwent a second successful phalloplasty, although this patient engaged in heavy smoking,39 a known risk factor for impaired wound healing independent of BMI.46 Ascha et al found that patients undergoing radial forearm flap phalloplasty experienced fewer complications and had a higher BMI than patients undergoing anterolateral thigh flap phalloplasty.38 However, Wirthmann et al showed that there was a trend (though not significant) toward complications for patients with a BMI greater than 25 undergoing radial forearm flap phalloplasty.39 Watanabe et al suggested that BMI can be useful, in tandem with radiographic imaging, when selecting type of donor flap to use for penile creation in phalloplasty.33 Similarly, for vaginoplasty, data on complications stratified by BMI are limited,24 and the existing data are too sparse to lead to definitive conclusions about the use of BMI in assessing surgical candidacy.

Quiz Ref IDRisks for patients with a higher BMI precede the operating table, such as the risks accompanying weight loss attempts to qualify for surgery. Losing weight safely or sustainably is difficult and often not achievable for most patients recommended to pursue weight loss.47 It can even be harmful for some individuals to attempt any weight changes, especially those with an active or previous eating disorder, which is characteristic of a large portion of trans individuals.48,49 Additionally, permanent weight loss attempts often result in cycles of weight loss and regain, which are ineffective and have their own health risks.50

We must consider the ethics of recommending that patients pursue medical or surgical interventions for weight loss before undergoing GAS without evidence that weight loss will significantly affect surgical outcomes as well as long-term outcomes in cases in which patients lose weight preoperatively and then experience postoperative weight regain. Lastly, some fat individuals regard their body size as part of their identity16,51 and do not want to attempt any kind of weight change. Recommending weight loss to fat individuals whose trans identities incur significant social criticism can similarly be perceived as a negative judgment and thereby damage the patient-surgeon relationship.

Shared Decision Making

In the absence of ample data, shared decision making supports informed consent. Increased risk of complications is often used to rationalize denying surgery to fat patients, as surgeons operating on individuals who may be at higher risk of complications could be accused of poor judgment or even face litigation if problems arise intraoperatively.52,53 Creating a more equitable division of decision-making responsibility between patients and surgeons can mitigate surgeons' fears of performing unsafe surgeries or patients' fears of experiencing poor outcomes. This goal can be achieved by proper informed consent through patient education and by allowing patients to be involved in the final decision.

Fear of litigation does not adequately justify refusal to operate, especially if the complications are manageable through wound care or revision surgeries. Even data on serious complications, like total flap loss, can help set patient expectations and possibly reduce legal action stemming from miscommunication. A paradigm of robust informed consent and collaboration encourages patient autonomy and strengthens patient-surgeon relationships.

Equitable Access to Surgery

Evidence regarding causes of fatness increasingly points toward macro-structural factors,54 which, alongside structural stigma, contribute to health inequalities.55,56 In the case of other stigmatized characteristics, such as race, attempts to address stigma aim to remove its effects on the patient rather than remove the characteristic itself. Thus, if it is assumed that people will continue to have diverse body sizes, solutions should be sought that will allow surgeons to safely operate on individuals of all sizes, including fat individuals.

Quiz Ref IDWe recognize that, in addition to explicit, intentional BMI thresholds, de facto BMI thresholds for surgery also exist,9 which include technical difficulties and equipment limitations. We hope these barriers to care can be resolved through innovation and investment in equipment, such as operating tables and longer tools suited for patients at high weights or with more tissue.57 Bariatric surgery specialists can model learning proper techniques and using equipment for safer operations.57 Examples from colorectal surgery include alternative incision sites and use of prophylactic mesh when there is more visceral fat.44 Preoperative radiographic imaging for flap surgeries, such as phalloplasty, can inform procedure decision making and planning.7,58,59 BMI can also be used to identify cases appropriate for less experienced surgeons.43

Access to GAS for fat trans people will not improve if BMI thresholds continue to bar patients from care without critical consideration of their use. BMI lacks the nuance to fully inform surgical candidacy. While still acknowledging the discriminatory origins of BMI, we believe its usefulness remains due to its ubiquity in the existing surgical outcomes literature. In a vacuum where no weight stigma exists, BMI is a helpful metric for data collection and procedural decision making, as well as for innovation of novel solutions in surgery for fat individuals. The problem is that BMI can enable and reinforce weight stigma, and that is what we must avoid. When assessing surgical candidacy, the risks associated with high BMI must be weighed against the benefits of GAS, which can be life-changing and sometimes even lifesaving.

Sign in to take quiz and track your certificates

The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

Article Information

AMA Journal of Ethics

AMA J Ethics. 2023;25(7):E496-506

AMA CME Accreditation Information

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.If applicable, all relevant financial relationships have been mitigated.

Editor's Note: The case to which this commentary is a response was developed by the editorial staff.

Conflict of Interest Disclosure The author(s) had no conflicts of interest to disclose.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Author Information:

  • Elijah Castle is an associate research coordinator in the Department of Urology at New York University Langone Health and is pursuing a master's degree in bioethics at the New York University School of Global Public Health in New York City. He works in patient-centered research, addressing topics such as patient-clinician relationships, knowledge dissemination and health education, the impacts of weight stigma on provisions of care, gender-affirming care for trans youth and adolescents, and patient-reported outcomes in gender-affirming surgery; Laura Kimberly, PhD, MSW, MBE is an assistant professor in the Hansjörg Wyss Department of Plastic Surgery and the Department of Population Health at the New York University Grossman School of Medicine in New York City. Her research examines ethical and psychosocial considerations in gender-affirming care, including centering patients' lived experiences of embodied identity over the life course; Gaines Blasdel is a medical student at the University of Michigan Medical School in Ann Arbor. He has conducted gender-affirming surgery research in the Department of Urology at New York University Langone Health and previously worked directly with transgender youth and young people living with HIV at the Callen-Lorde Community Health Center adolescent clinic, where he also developed gender-affirming surgery resources and programs. His academic interests include patient-centered outcomes research in gender-affirming surgery; Augustus Parker is a third-year medical student at the New York University (NYU) Grossman School of Medicine in New York City. He will begin his plastic surgery residency at NYU in 2023. His academic interests include surgical innovation and patient-reported outcomes research in gender-affirming surgery; Rachel Bluebond-Langner, MD is the Laura and Isaac Perlmutter Associate Professor of Reconstructive Plastic Surgery in the Hansjörg Wyss Department of Plastic Surgery at the New York University (NYU) Grossman School of Medicine in New York City. She also serves as co-director of transgender surgery services at NYU and is an associate editor of Plastic and Reconstructive Surgery. She performs the full spectrum of gender-affirming genital and chest surgeries in a multidisciplinary setting in addition to gender-affirming surgery outcomes research; Lee C. Zhao, MD, MS is a reconstructive urologist and a co-director of the Transgender Reconstructive Surgery Program at New York University Langone Health in New York City. He performs primary and revision gender-affirming surgery as part of a multidisciplinary team. He also serves as an associate editor of the Journal of Sexual Medicine and was a coauthor of the American Urologic Association core curriculum on gender-affirming surgery and guidelines on male urethral stricture.

 Defining adult overweight & obesity.  Centers for Disease Control and Prevention. Reviewed June 3 , 2022. Accessed December 24, 2022. https://www.cdc.gov/obesity/basics/adult-defining.html
Martinson  TG, Ramachandran  S, Lindner  R, Reisman  T, Safer  JD.  High body mass index is a significant barrier to gender-confirmation surgery for transgender and gender-nonbinary individuals.  Endocr Pract. 2020;26(1):6–15.Google ScholarCrossref
Young  T, Peppard  PE, Gottlieb  DJ.  Epidemiology of obstructive sleep apnea: a population health perspective.  Am J Respir Crit Care Med. 2002;165(9):1217–1239.Google ScholarCrossref
Peppard  PE, Young  T, Barnet  JH, Palta  M, Hagen  EW, Hla  KM.  Increased prevalence of sleep-disordered breathing in adults.  Am J Epidemiol. 2013;177(9):1006–1014.Google ScholarCrossref
Peppard  PE, Young  T, Palta  M, Dempsey  J, Skatrud  J.  Longitudinal study of moderate weight change and sleep-disordered breathing.  JAMA. 2000;284(23):3015–3021.Google ScholarCrossref
Wharton  S, Lau  DCW, Vallis  M,  et al.  Obesity in adults: a clinical practice guideline.  CMAJ. 2020;192(31):E875–E891.Google ScholarCrossref
Winfield  RD, Reese  S, Bochicchio  K, Mazuski  JE, Bochicchio  GV.  Obesity and the risk for surgical site infection in abdominal surgery.  Am Surg. 2016;82(4):331–336.Google ScholarCrossref
Saiganesh  H, Stein  DE, Poggio  JL.  Body mass index predicts operative time in elective colorectal procedures.  J Surg Res. 2015;197(1):45–49.Google ScholarCrossref
Castle  E, Blasdel  G, Shakir  NA, Zhao  LC, Bluebond-Langner  R.  Weight stigma mitigating approaches to gender-affirming genital surgery.  Plast Aesthet Res. 2022;9(3):20.Google ScholarCrossref
Hedenstierna  G, Tokics  L, Scaramuzzo  G, Rothen  HU, Edmark  L, Öhrvik  J.  Oxygenation impairment during anesthesia: influence of age and body weight.  Anesthesiology. 2019;131(1):46–57.Google ScholarCrossref
Brownstone  LM, DeRieux  J, Kelly  DA, Sumlin  LJ, Gaudiani  JL.  Body mass index requirements for gender-affirming surgeries are not empirically based.  Transgend Health. 2021;6(3):121–124.Google ScholarCrossref
Phelan  SM, Burgess  DJ, Yeazel  MW, Hellerstedt  WL, Griffin  JM, van Ryn  M.  Impact of weight bias and stigma on quality of care and outcomes for patients with obesity.  Obes Rev. 2015;16(4):319–326.Google ScholarCrossref
Paine  EA.  “Fat broken arm syndrome”: negotiating risk, stigma, and weight bias in LGBTQ healthcare.  Soc Sci Med. 2021;270:113609.Google ScholarCrossref
NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.  Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. National Heart, Lung, and Blood Institute; 1998. Report 98-4083. Accessed June 15, 2023. https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/2007154166-as-ob_gdlns.pdf
Tomiyama  AJ.  Weight stigma is stressful.  A review of evidence for the cyclic obesity/weight-based stigma model.  Appetite. 2014;82:8–15.Google Scholar
Saguy  AC, Ward  A.  Coming out as fat: rethinking stigma.  Soc Psychol Q. 2011;74(1):53–75.Google ScholarCrossref
Strings  S.  Fearing the Black Body: The Racial Origins of Fat Phobia. New York University Press; 2019.
Strings  S.  Obese Black women as “social dead weight”: reinventing the “diseased Black woman.”  Signs. 2015;41(1):107–130.Google ScholarCrossref
Thorpe  RJ  Jr, Parker  LJ, Cobb  RJ, Dillard  F, Bowie  J.  Association between discrimination and obesity in African-American men.  Biodemography Soc Biol. 2017;63(3):253–261.Google ScholarCrossref
Bidstrup  H, Brennan  L, Kaufmann  L, de la Piedad Garcia  X.  Internalised weight stigma as a mediator of the relationship between experienced/perceived weight stigma and biopsychosocial outcomes: a systematic review.  Int J Obes (Lond). 2022;46(1):1–9.Google ScholarCrossref
Almazan  AN, Keuroghlian  AS.  Association between gender-affirming surgeries and mental health outcomes.  JAMA Surg. 2021;156(7):611–618.Google ScholarCrossref
Pittelkow  EM, Duquette  SP, Rhamani  F, Rogers  C, Gallagher  S.  Female-to-male gender-confirming drainless mastectomy may be safe in obese males.  Aesthet Surg J. 2020;40(3):NP85–NP93.Google ScholarCrossref
Rothenberg  KA, Gologorsky  RC, Hojilla  JC,  et al.  Gender-affirming mastectomy in transmasculine patients: does obesity increase complications or revisions?  Ann Plast Surg. 2021;87(1):24–30.Google Scholar
Ives  GC, Fein  LA, Finch  L,  et al.  Evaluation of BMI as a risk factor for complications following gender-affirming penile inversion vaginoplasty.  Plast Reconstr Surg Glob Open. 2019;7(3):e2097.Google ScholarCrossref
Berry  MG, Curtis  R, Davies  D.  Female-to-male transgender chest reconstruction: a large consecutive, single-surgeon experience.  J Plast Reconstr Aesthet Surg. 2012;65(6):711–719.Google ScholarCrossref
Frederick  MJ, Berhanu  AE, Bartlett  R.  Chest surgery in female to male transgender individuals.  Ann Plast Surg. 2017;78(3):249–253.Google ScholarCrossref
Donato  DP, Walzer  NK, Rivera  A, Wright  L, Agarwal  CA.  Female-to-male chest reconstruction: a review of technique and outcomes.  Ann Plast Surg. 2017;79(3):259–263.Google ScholarCrossref
McEvenue  G, Xu  FZ, Cai  R, McLean  H.  Female-to-male gender affirming top surgery: a single surgeon's 15-year retrospective review and treatment algorithm.  Aesthet Surg J. 2017;38(1):49–57.Google ScholarCrossref
Kääriäinen  M, Salonen  K, Helminen  M, Karhunen-Enckell  U.  Chest-wall contouring surgery in female-to-male transgender patients: a one-center retrospective analysis of applied surgical techniques and results.  Scand J Surg. 2017;106(1):74–79.Google ScholarCrossref
van de Grift  TC, Elfering  L, Bouman  MB, Buncamper  ME, Mullender  MG.  Surgical indications and outcomes of mastectomy in transmen: a prospective study of technical and self-reported measures.  Plast Reconstr Surg. 2017;140(3):415e–424e.Google ScholarCrossref
Knox  ADC, Ho  AL, Leung  L,  et al.  A review of 101 consecutive subcutaneous mastectomies and male chest contouring using the concentric circular and free nipple graft techniques in female-to-male transgender patients.  Plast Reconstr Surg. 2017;139(6):1260e–1272e.Google ScholarCrossref
Gallagher  S, Rahmani  F, Russell  A, Duquette  S.  A drain-free technique for female-to-male gender affirmation chest surgery decreases morbidity: outcomes from 306 consecutive masculoplasties.  Ann Plast Surg. 2019;83(1):15–21.Google ScholarCrossref
Watanabe  T, Sakurai  T, Mukai  Y, Kimata  Y, Namba  Y.  Risk factors for postoperative hematoma after chest wall contouring for female-to-male transsexuals: a clinical study.  Acta Med Okayama. 2019;73(5):441–447.Google Scholar
Stein  MJ, Grigor  E, Hardy  J, Jarmuske  M.  Surgical and patient-reported outcomes following double incision and free nipple grafting for female to male gender affirmation: does obesity make a difference?  J Plast Reconstr Aesthet Surg. 2021;74(8):1743–1751.Google ScholarCrossref
Naides  AI, Schultz  JJ, Shulzhenko  NO, Keith  JD.  Chest masculinization technique and outcomes in 72 double-incision chest-contouring procedures with free nipple grafting.  Plast Reconstr Surg Glob Open. 2021;9(3):e3459.Google ScholarCrossref
Rifkin  WJ, Robinson  IS, Kloer  C,  et al.  Gender-affirming mastectomy: comparison of periareolar and double incision patterns.  Plast Reconstr Surg Glob Open. 2022;10(5):e4356.Google ScholarCrossref
Gaither  TW, Awad  MA, Osterberg  EC,  et al.  Postoperative complications following primary penile inversion vaginoplasty among 330 male-to-female transgender patients.  J Urol. 2018;199(3):760–765.Google ScholarCrossref
Ascha  M, Massie  JP, Morrison  SD, Crane  CN, Chen  ML.  Outcomes of single stage phalloplasty by pedicled anterolateral thigh flap versus radial forearm free flap in gender confirming surgery.  J Urol. 2018;199(1):206–214.Google ScholarCrossref
Wirthmann  AE, Majenka  P, Kaufmann  MC,  et al.  Phalloplasty in female-to-male transsexuals by Gottlieb and Levine's free radial forearm flap technique-a long-term single-center experience over more than two decades.  J Reconstr Microsurg. 2018;34(4):235–241.Google Scholar
Watanabe  T, Namba  Y, Kimata  Y.  Flap selection algorithm based on the body mass index for phalloplasty in female-to-male transgender: techniques and outcomes.  J Reconstr Microsurg Open. 2021;6(2):e57–e62.Google Scholar
Spennato  S, Ederer  IA, Borisov  K,  et al.  Radial forearm free flap phalloplasty in female-to-male transsexuals—a comparison between Gottlieb and Levine's and Chang and Hwang's technique.  J Sex Med. 2022;19(4):661–668.Google ScholarCrossref
Bordas  N, Stojanovic  B, Bizic  M, Szanto  A, Djordjevic  ML.  Metoidioplasty: surgical options and outcomes in 813 cases.  Front Endocrinol (Lausanne)2021;12:760284.Google ScholarCrossref
Uchida  T, Higure  T, Kawakami  M,  et al.  What factors affect the operative time of robot-assisted laparoscopic radical prostatectomy?  Surg Endosc. 2021;35(8):4436–4443.Google ScholarCrossref
Aquina  CT, Rickles  AS, Probst  CP,  et al.  Visceral obesity, not elevated BMI, is strongly associated with incisional hernia after colorectal surgery.  Dis Colon Rectum. 2015;58(2):220–227.Google ScholarCrossref
van der Sluis  WB, de Bruin  RJM, Steensma  TD, Bouman  MB.  Gender-affirmation surgery and bariatric surgery in transgender individuals in the Netherlands: considerations, surgical techniques and outcomes.  Int J Transgend Health. 2022;23(3):355–361.Google ScholarCrossref
Chang  LD, Buncke  G, Slezak  S, Buncke  HJ.  Cigarette smoking, plastic surgery, and microsurgery.  J Reconstr Microsurg. 1996;12(7):467–474.Google ScholarCrossref
MacLean  PS, Wing  RR, Davidson  T,  et al.  NIH working group report: innovative research to improve maintenance of weight loss.  Obesity (Silver Spring). 2015;23(1):7–15.Google ScholarCrossref
Sequeira  GM, Miller  E, McCauley  H, Eckstrand  K, Rofey  D.  Impact of gender expression on disordered eating, body dissatisfaction and BMI in a cohort of transgender youth.  J Adolesc Health. 2017;60(2)(suppl 1):S87.Google Scholar
Linsenmeyer  WR, Katz  IM, Reed  JL, Giedinghagen  AM, Lewis  CB, Garwood  SK.  Disordered eating, food insecurity, and weight status among transgender and gender nonbinary youth and young adults: a cross-sectional study using a nutrition screening protocol.  LGBT Health. 2021;8(5):359–366.Google ScholarCrossref
Bacon  L, Aphramor  L.  Weight science: evaluating the evidence for a paradigm shift.  Nutr J. 2011;10:9.Google ScholarCrossref
McPhail  D, Orsini  M.  Fat acceptance as social justice.  CMAJ. 2021;193(35):E1398–E1399.Google ScholarCrossref
Zubarevich  A, Szczechowicz  M, Zhigalov  K,  et al.  Surgical redo mitral valve replacement in high-risk patients: the real-world experience.  J Card Surg. 2021;36(9):3195–3204.Google ScholarCrossref
Moonesinghe  SR, Mythen  MG, Grocott  MPW.  High-risk surgery: epidemiology and outcomes.  Anesth Analg. 2011;112(4):891–901.Google ScholarCrossref
Caballero  B.  Humans against obesity: who will win?  Adv Nutr. 2019;10(suppl 1):S4–S9.Google Scholar
Talumaa  B, Brown  A, Batterham  RL, Kalea  AZ.  Effective strategies in ending weight stigma in healthcare.  Obes Rev. 2022;23(10):e13494.Google ScholarCrossref
Calogero  RM, Tylka  TL, Mensinger  JL.  Scientific weightism: a view of mainstream weight stigma research through a feminist lens.  In: Roberts  TA, Curtin  N, Duncan  LE, Cortina  LM, eds.  Feminist Perspectives on Building a Better Psychological Science of Gender. Springer International Publishing; 2016:9–28.Google Scholar
 Recommendations for facilities performing bariatric surgery.  American College of Surgeons. September 1 , 2001. Accessed December 23, 2022. https://www.facs.org/about-acs/statements/recommendations-for-facilities-performing-bariatric-surgery/
Sinove  Y, Kyriopoulos  E, Ceulemans  P, Houtmeyers  P, Hoebeke  P, Monstrey  S.  Preoperative planning of a pedicled anterolateral thigh (ALT) flap for penile reconstruction with the multidetector CT scan.  Handchir Mikrochir Plast Chir. 2013;45(4):217–222.Google Scholar
Annen  AW, Heston  AL, Dugi  DD  III,  et al.  Masculinizing genital surgery: an imaging primer for the radiologist.  AJR Am J Roentgenol. 2020;214(1):W27–W36.Google ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.


Name Your Search

Save Search

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.