Transcript

Chala:

I'm tired of feeling like I'm being tolerated. 

HC: 

This is Chala June.

Chala:

Because if there's one thing about me, one, I would love to be intolerable. I will be intolerably trans. And anyone who can't make space for that just can't make space for me.

HC:

It’s taken them a long time to get here, to being loud and proud and intolerably trans.  They’re 26, just a couple inches shy of 6 feet tall, and their style is self-described as on the Mr. Rogers to Ms. Frizzle spectrum. We met last summer when I did a fellowship at Bon Appétit where they work as an associate editor.  It’s hard for me to wrap my mind around someone not tolerating Chala. But unfortunately, our society –  and our medical system – is set up to not tolerate, their Black, queer, and large trans body. I could tell you about so many of the structural barriers erected to keep trans folks from accessing the life-saving care they need, but we’d be here all day. 

So, I’m going to tell you about one barrier to accessing one type of surgery and the way it affected one person – Chala. When they decided they were ready for top surgery, a mastectomy to masculinize their chest, they were told they were too fat for the procedure. To tell you about their experience, I’ll be discussing anti-fatness, disordered eating, and suicidal ideation. I know all of that can be triggering, so please take care of yourself. 

Growing up, Chala’s family had no room for queerness. 

Chala:

So I am the youngest of four. My dad emigrated from Congo. So, like, kind of first-gen, a lot of first-gen morals and expectations. Mother is a Jehovah's Witness.

HC:

There was a lot about themself that they couldn’t understand and they didn’t have anyone to talk to about it 

Chala: 

There was no room made for gender variance at all. My mom being like so deep in her faith, but then also my dad being like a very traditional African man. Any sort of emotional stuff you really just kind of dealt with and navigated on your own. Because my dad was just like, ”Go talk to your mother.” And my mom's like, “Well, here's what Jesus has to say.”

HC:

Their boobs started developing young and at first, it felt like they were entering the exclusive, mature club that their Mom and sisters were a part of.

Chala:

Like as I just went deeper into puberty and developed more I was like I don't know if I like this club. I don't know if this is quite the club that I want to be in. 

HC:

Their body started to elicit attention and they were bombarded with the message that the attention was their fault.

Chala: 

No 13-year-old should wear a D-cup. Trauma um trauma. 

HC:

Their chest grew faster than their spine, which caused chronic back pain from a young age. They did some physical therapy in high school, but insurance didn’t cover enough sessions to make much of a difference. They felt highly limited in daily life

Chala: 

Like in gym class and stuff, like all of the fucking running and jumping and shit and like, I hated doing it and I felt a lot of shame around that because I've always been a fat person and it was like, “Oh, well, of course, like, Chala doesn't like running and jumping, you know, they're fat,” but it’s like my fucking back hurts.

HC:

In High School, they found their first queer community through the Gay Straight Alliance and realized they were bisexual.

Chala: 

So I was living as like a cis bisexual for quite some time, which cringe. Cringe. 

HC No offense to the cis bisexuals

Chala: no offense but for me personally cringe. Cause, you know, you take that first identity and you just sprint. 

HC:

They went to Emerson College with some awareness of binary trans identity, but no knowledge of gender fluidity. it wasn’t until their junior year that they realized they were nonbinary

Chala: 

I'm just like sitting in my dorm room. I'm on Tumblr, classically, and I just saw, like, something, something androgynous. And my brain went hooo and like because I think it was like I saw it like as a gender identity and not just as like an adjective. And I was like, wait, wait, wait a second wait.

HC:

Chala came out and spent the years after college exploring their gender, and working in food. They were a short-order cook, a prep baker, a cheesemonger, a barista, and a line cook. After a stint in California, they landed in New York where they started seeing a chiropractor in the fall of 2019. 

Chala: 

She was like, yeah I like two of your vertebrae in your lower back are just like resting on a nerve just kind of like pinchin’.

HC:

She recommended they get a breast reduction, which they had been considering for a long time. She said their back wouldn’t heal without relieving the pressure of their breasts, which had been crushing their spine for more than a decade.

Chala:

I think the last time I got my chest measured it was something like a like a double-F.

HC:

By that point, Chala was ready for their body to better reflect their identity. They were tired of being constantly misgendered, tired of being ma’amed and ready to give their back a break. 

Chala: 

 I was like thinking through it and I was like, Well, if I'm already going to go under the knife, we might as well just get it all out the way.

HC:

So Chala decided to get top surgery - breast removal and reconstruction of the chest to be more masculine. It’s a major undertaking. In order to qualify, patients need a letter from a therapist stating that the surgery is appropriate and necessary, a surgical consultation, insurance approval, etc.  It’s an outpatient procedure that takes from an hour and a half to four hours to perform and then a month plus to recover from.

Chala was ready to get the process rolling when Covid came along and delayed their search for a surgeon. Then they ended up at the bottom of a 6 month waiting list. When they finally got a consultation in January 2021, they kept their expectations in check, they didn’t want to get their hopes up 

Chala: 

Because I'm like, used to just like expecting to be disappointed.

HC:

Even so, nothing could have prepared them for what happened when the surgeon came into the exam room

Chala: 

She, like, quite literally stood there, like did a BMI calculator on her phone and was like, “Yeah, so come back in like six months, maybe try to lose around like 50 pounds and then we can talk.” Like it was an incredibly triggering experience. 

HC:

I was shocked when they told me this. I had top surgery about a year and a half ago, but because I’m slim my weight never came up during any part of the process. I didn’t even know it was a factor.

But Chala’s experience isn’t unusual. Many surgeons refuse to do top surgery on fat people. They cite increased risk of complications and say that patients won’t be happy with the results. They use a measure known as BMI – the body mass index – to determine who they’ll operate on. 

The BMI was developed by a Belgian mathematician almost 200 years ago based on the bodies of cisgender, white men. He was looking for a statistical way to measure weight at the population level. It was never intended to gauge the health of individuals - he was a statistician, not a doctor. In the 1940s the MetLife insurance company used BMI in actuarial tables to determine an average or “ideal” man, based on their primarily white policyholders. BMI doesn’t account for bone density, muscle mass, age, ethnicity, or sex. There are doctors who argue it should be scrapped altogether. 

Dr. Alexes Hazen: 

I think it's really imperfect 

HC:

This is Dr. Alexes Hazen. a top surgeon who doesn’t have a BMI limit in her practice

Dr. Alexes Hazen: 

It's like square footage in a house. You know, it's it tells you some information, but it really doesn't tell you, like, what the layout is, you know? So that means, like some people with a high BMI can be extremely healthy and some people can be very unhealthy. 

HC:

Although Dr. Hazen doesn’t use BMI cut-offs, she understands why other surgeons do.

Dr. Alexes Hazen: 

I think it's harder, it's more work. And so some people just aren't willing to do that. And for a lot of plastic surgeons it's almost viewed as elective. So, you know, if you if you have a gallbladder attack and you need your gallbladder out and you're, you know, the surgeon is not going to say, well, you have a high BMI, they're going to say, we'll do this, but you're at higher risk. 

HC:

It’s not that Dr. Hazen doesn’t think about her patients’ weight at all. Her surgical approach will differ depending on the patient’s breast size and skin elasticity. For people with small chests very small incisions can be made at the base of the nipple to remove tissue. But for most people, longer incisions must be made across the chest. The length of those incisions will depend on the amount of tissue needing to be removed. Larger chests can take longer to operate on, and are often more challenging for the surgeon.  

Surgeons have different techniques they specialize in. Some prefer curved incisions, others straight, some connect the incisions in the middle, others don’t. So depending on who your surgeon is, your chest can look radically different post-op.

With increased demand for top surgery, more surgeons now offer it. Unfortunately, some seem to have their wallets and not the safety of their patients in mind.  Fat people who’ve been denied or told to lose large amounts of weight might wind up stuck with less trustworthy surgeons as their only options for care.

Chala:
There are so many people who are genuinely desperate for surgery and these surgeons are really taking advantage of that. 

HC:

Chala has friends who saw surgeons who they now consider predatory. Some have needed major revisions requiring additional surgeries to correct botched procedures. One surgeon in Miami who is very active on TikTok and Instagram received backlash recently after a fat patient had to be hospitalized with a serious infection a few weeks after surgery. The technique she used has been shown to be risky for people with high BMIs. When the patient sought compensation they discovered the surgeon had no malpractice insurance and so there was little legal recourse available.  

It can be incredibly challenging to find a surgeon who takes your insurance, has availability, whose results you like, and who you trust.  Having a high BMI can make that search more challenging and more painful.  The surgeon Chala saw didn’t look at the person in front of her, just the number on her calculator that needed to come down. That dehumanization caused Chala to have

Chala: 

A really bad spiral in a way that I hadn't in a while and quite honestly, like experienced like suicidal ideation in a way that I hadn't in a while and that was a really hard thing to bounce back from.

HC:

Chala wasn’t about to go back to such a callous surgeon, but they also weren’t emotionally ready to look for a new one. 

We’re going to leave Chala for a moment to dig deeper into why surgeons use BMI cut-offs. Not only is top surgery more difficult on heavier people, surgeons also take it for granted that fat people have a higher risk of complications–not just for top surgery but when it comes to any kind of surgery. 

For top surgery, complications can range in severity. Seroma, which is the accumulation of fluid, can be minor, as in just requiring an office visit to drain, or it can be more long-term and require going back to the operating room. Wounds can take longer to heal, which can extend recovery time. And more seriously, people can also develop blood clots. Here’s Dr. Hazen again

Dr. Alexes Hazen:  

So I think, you know, it's understandable that you wouldn't want to take on a surgery that already has a risk of complications and then add on a known factor that will increase that risk. 

HC:

But a few recent studies suggest that BMI doesn’t actually increase the risk of complications from top surgery. Two studies from 2021, from The University of Ottawa and Georgetown University both, found patients with BMIs considered obese have comparable top surgery outcomes to everyone else. Another study from the University of California San Francisco-East Bay found that obesity alone shouldn’t disqualify people from top surgery. This is why Hazen looks at overall health instead of relying on the BMI.

In contrast, other research shows that being underweight or malnourished can increase your risk of complications. A 2020 study from Duke University called malnourished surgery patients a silent epidemic– And keep in mind that people who are crash dieting to lose weight, no matter their body size, can be malnourished. So telling people to lose weight to decrease their risk of complications could backfire.  Some experts say that the surgical focus on BMI is inherently discriminatory, and that doctors are notoriously fatphobic.

Dr. Lacie Parker: 

I still have a lot of clients who express concern even visiting their primary health provider, because they know that they are going to experience weight stigma. So it can be a barrier to getting good care.

HC:

This is Lacie Parker, a psychotherapist who works with queer people and focuses on eating concerns and body image.

Dr. Lacie Parker: 

So weight stigma is one of the very few stigmas where it is still seen to be okay, to be explicitly fatphobic or have an explicit weight bias. So, you know, and it also kind of ties into this rhetoric of, you know, being thin is better and that you can control your weight and that if you are in a larger body, then you're automatically unhealthy.

HC:

Because gender-affirming surgeries are often still categorized as elective, there’s much more leeway for turning people away. It also allows surgeons to focus on aesthetics over access.  Plastic surgeons are distinct from other doctors because their patients become their portfolio. They post before and after photos on their websites and social media So they might not want to operate on someone whose results won’t be to their own standard. I asked Dr. Hazen if surgeons make decisions about who to operate on with their portfolio in mind, and she said 100%. In contrast, the aesthetics of their results were pretty low on Chala’s priority list

Chala:

You know, I could look like I got fucking mauled, honestly. Like I'll put a t-shirt on just take them away. 

HC:

But no matter the reason surgeons have for requiring weight loss, aesthetic or not, they might not be considering how damaging telling people to lose weight can be. Trans people are more likely to struggle with disordered eating than cis people. Statistics vary, but it’s estimated that trans people experience eating disorders at 2 to 5 times the rate of their peers. 

There are lots of contributing factors to these high rates – discrimination and bullying, family rejection, and, most prevalently, gender dysphoria.

Dr. Lacie Parker: 

A lot of that has to do with trying to mold your body into what you want it to be, but also what society wants your body to be. 

HC:

Telling someone who has a fraught relationship to their body that they have to lose weight risks sending them back down a self-destructive path.  

Chala: 

 I have, like, struggled with binge eating my entire life. I was a very lonely kid despite growing up in a big family. So food was how I self-soothed.

HC:

For Chala food has been a source of joy and comfort, a space for creativity and expression. 

Chala:

My childhood hero was literally. Emeril Lagasse. Like I'd be like, Mom, you're not doing it how Emeril does it.

HC:

But food has also been a source of shame, something to deny themself to fit into what other people expect from them, a thing to run from.

Chala: 

I have a distinct memory of like my mom had made, like something really good for dinner one time I like tried to get seconds because like my brother just had seconds. And my dad said to me something along the lines of like, “Oh, he can have more because he's a growing boy. You need to not eat like a boy.” And that was an early just like dissonance, both between, like, my eating patterns and my gender. And I was like, I don't understand what any of this is supposed to mean Nor how i’m supposed to apply it to my life. And so the binge eating would be balanced out by periods of starving myself and only really eating like once a day because I feel terrible about my body.

HC:

Chala remained in this cycle all the way through their Junior year of college. They were a Resident Advisor, worked two jobs, was president of the Black Student Union, and was the recruitment head for their sorority. All of it was part of… 

Chala: 

…trying to avoid sitting with myself and my thoughts and sleeping and healthy human habits. 

HC:

But they couldn’t avoid their feelings forever. They had a breakdown after the 2016 election. 

Chala: 

Because Boston got real scary. It was already very scary. But then I was just I couldn't go to class. I couldn't look anybody in the face. I was having really bad nightmares.

HC:

Chala checked themself into a hospital for psychiatric treatment twice in the following months. The second time they did an outpatient program that was exclusively for queer and trans people. It was their first time meeting gender-expansive and nonbinary people. their first glimpse of an identity that could encapsulate all aspects of themeself. Bisexuality had identified who they were attracted to, but not who they were. 

Chala:
And the whole time they like asked pronouns every morning and like eh she/her. But being in this group therapy environment, in this intensive group therapy environment with a bunch of trans people, I was like, why does this sound so familiar? Why is this hitting so close to home? And I remember distinctly someone saying, if you have to ask yourself, or search, “am I trans?” You probably are. And I was like, You can't say this to me. 

HC:

About a week after leaving the program is when they fell down the Tumblr androgyny rabbit hole and came out. Around the time they were realizing their identity, they were also letting themself fall back in love with food.

They got their first job working in a kitchen and found themself in a dedicated environment…

Chala: 

…where I was able to really learn so much about food. And that changed a lot of my relationship to it because it became less about this. Like, I mean, as with all disordered eating, it became less about the control of it and like feeling out of control, which is what it was for me, and it was less about feeling out of control and more about just like the learning aspect of it and creating the space to just be a big nerd about kohlrabi.

HC:

But after two years of working in food and eating more consistently, the consult with the top surgeon sent them back into destructive calorie restriction. They knew they had to lose weight so…

Chala: 

It was hard to get myself to eat. And I got very restrictive with what I was eating because I was so sad. And. Yeah. Not eating and then binge eating and then not eating, which doesn't help anything. 

HC:

The attempt to restrict calories after a binge is part of what’s referred to as the binge-restrict pendulum. So you can picture your food consumption as a weight on a string. If you’re consistently eating the amount of food your body needs, you’ll hang at the equilibrium in the middle. If you intentionally reduce calories or skip meals you pull the pendulum to the restriction side. The further you pull it, the further it’ll swing towards binging once you can no longer deny yourself.  Often, a binge will be followed by shame that’ll cause you to try to restrict even further, which just causes the pendulum to swing more forcefully.

After months of restriction and depression, Chala took a trip to California to visit their best friend. 

Chala: 

Spending time with them always reminds me of what is and isn’t important. Like this is someone who has been known since we were six-years-old. Like they have seen me in every iteration. 

HC:

The two took shrooms while camping in the desert and Chala… 

Chala: 

…just found this moment of faith and just, like, knew that I was going to make it happen. And I was going to make it happen in a way that felt good for me and felt true to who I am. And I was going to make it happen. On my terms. And so I did come back from that like refreshed and renewed to commit to just reevaluating all of the habits I had in my life. 

HC:

They committed to intentionally treating themself better, to drinking more water, spending more time outside, and to cooking and eating the vegetables they love.

Chala:

 I would order this farm box and it was like a Chopped challenge and I was like. you have two pounds of sunchokes, like Swiss chard, you know? And it's like, All right, let's go.

HC:

They took their time, didn’t try to rush to meet that 6-month timeline the NYU surgeon set. They found a different surgeon at Mt. Sinai who said they’d only have to lose 15 pounds, so a lot of the pressure was lifted. Chala was able to lose weight on their own terms and at their own pace.

Chala:

But it worked. And I think really what it was more than anything else for me and I think it continues to ring true is just like it was about the shift in like my mindset and how I treated myself more than anything else.

HC:

They ended up losing about 60 pounds, more than the original surgeon prescribed. They scheduled top surgery with their new doctor for August 2022, more than a year and a half after that first consultation.

As Chala approached surgery there were lots of things they were nervous about. Surgery is scary, the prospect of complications and being helpless during recovery is scary. And… 

Chala: 

Being perceived as a black man is very scary. 

HC:

As the date got closer there was a lot of trepidation and excitement swirling around in Chala’s head. Their sister who’s an ER tech came up from Maryland to take care of them. She drove them to Mount Sinai

Chala:

And we were trying to navigate like Chelsea traffic and she made a wrong turn that almost put us on to the Holland Tunnel. And she literally like I was like, no, we can't do this. And she like banged a U-turn like very illegally. Like there was a cop posted there that like weepweeped his lights. And I was like, just keep going. He is not he's not going to get in his car to stop, like just keep going. And we just kept going and it was fine, but we were just like, That could have been bad. She was like, I'm getting you there on time. So that was like a little pre-surgical stress moment. 

HC:

They had paperwork to fill out and enough time to talk to their other two siblings before the surgeon came in. He drew the lines on their chest to show where he’d be making his incisions

Chala: 

And I was nervous. But then we had like a moment because all morning I was thinking about the scene from Arrested Development, where Kitty is like, “say goodbye to these,” and she lifts up her shirt. And I was talking to my surgeon. I was like, “Did you ever watch Arrested Development?” He was like, “Yeah.” I was like, “All I can think about is ‘say goodbye to these.’” And like, we're both just cracking up. And I was like, “Okay, I'm ready.”

HC: Wow, that is so good. 

Chala: I was like, I'm ready for this. And then, you know, went into the O.R., laid down on that very warm table. I wasn't expecting it to be so, like, perfectly heated. You know, like tucked me in, I was like this is kinda nice, you know. 

HC: A pampering

Chala: A nice pampering and they put the I.V. in and put the gas mask on and we're like, all right, just take a few deep breaths. And I was like, okay, we're going to do this. And next thing I know, I'm just sitting up in a chair very cold afterward.

HC:

Their recovery has required a lot of patience. They didn’t have work to divert their attention, so had to just sit with their thoughts. 

Chala:

There was this, like, feeling of relief of just like, thank God it's actually happened. But I've also been in just like this odd headspace of… You know, I'm trying to practice radical acceptance and just like accepting how I am feeling instead of like shaming myself for not feeling how I think I should be feeling. Like, okay, you did the thing. Why aren't you, like, over-the-moon ecstatic about it? I'm like, well, my body hurts and like, I can't do shit for myself. And I'm like, in bed all day, just like watching TV. 

HC:

Part of that headspace has also been continued frustration over their protracted experience. When I decided to get top surgery, it was really easy. I went to the surgeon my GP recommended and she offered me an appointment for three months after that first meeting, but I chose to delay by a month. Chala had to go through months of research, waiting, and weight loss. It took them six times as long to get surgery. That’s been deeply frustrating, but it also felt inevitable to them.

Chala:

There wasn't going to be a world where everything went smoothly. That didn't exist for me. It wasn't going to because of the realities of medical fatphobia of medical racism. And. It was very frustrating as I was going through the process to see several people who I knew who had–even people I knew who had, like, realized that they were trans like years after I had–be able to get gender-affirming surgery before me. And. I carried a lot of that resentment until the day I was able to get surgery. I think a lot of it is still frustrating. You know, I think I do still carry a lot of that. 

HC:

They’ve been channeling that frustration into being a resource for other people in their situation. The good news is that…

Chala:

I'm definitely really happy with the results, especially just considering the sheer volume of boobage that needed to be removed. Like my surgeon was like, yeah, it was definitely one of the larger chests that I've had to operate on in quite some time. I was like, I'm sure, but like everything's even. My nipples are level, which is great. 

HC:

Now it’s been a few months, their recovery has been pretty smooth. Chala is back at work at Bon Appétit writing and editing about the food they love. They are able to dance and move freely, able to throw on a shirt without agonizing over their silhouette.

Chala:

 it is it's nice to be able to like actually walk with like my chest held high.

HC:

But now that their body better aligns with their identity, they have to reckon with the new way they're seen by those around them. Walking around the city, they’ve had to adjust to being perceived as a Black man. 

Chala: 

Like two days ago I was just like walking to my apartment.  I turned the corner, like, too close to this woman or something. And she just, like, jumped back. Like, she was so frightened, you know, by me coming around the corner. And I was like. “Bruh I'm just trying to get home, you know?” 

HC:

Before surgery, they could lean into feminity. Being perceived as a cis woman offered some protection, but it didn’t align with who they actually were. Now, if they appear too masculine, they face the discrimination of a Black man. If they lean more femme, they’re more easily clocked as trans, which can also put them in harm’s way

Chala:  

Because there's like the whole separate concern of getting gay bashed. 

HC:

Their body better aligns with who they are, but they can’t control how others see them nor how they’ll react to what they see. Chala doesn’t want to be seen as a threat or a victim.

Chala: 

That’s a large part of the reason why I've been spending a lot of time just by myself at home.

HC:

They’ve been able to find safety and freedom in queer community. Before surgery, they performed a couple times as their drag persona, Pisces Moon. After a couple months of healing, they’ve thrown themself back into drag with new confidence. I went to their first show back the Friday before halloween with some mutual trans friends. Purgatory, this bar in Bushwick, was packed with all kinds of queers, there to scream their heads off for Pisces and the other performers

[music and cheers from performance]

Chala:

I definitely feel like now I'm able to, like, do bigger gestures, to do more physicality. And even just my comfort in wearing clothing with more feminine silhouettes has really been boosted because I can wear them without immediately being perceived as a cis woman. And so I think that alone has allowed me to really expand and branch out in my artistry. 

[music and cheers from performance]

Chala:

And then, yeah, there's more physicality to it. The number that I had just done it 3 Dollar Bill, like it was literally me, just like jumping around and whipping a giant red ponytail and trying to open a mosh pit. Before surgery, I was like, I don't I don't jump.

But yeah. Even being able to like. You know wear a corset to do like a sexy demonic burlesque number. It was like such a difference, just like going to try the corset and I was like, “yes, this is exactly what I want with like no boobs flopping over the top.” You know, I was like, “This is perfect!”

HC: Yeah. Talk to me about, like, being shirtless on stage. 

Chala: Oh, it was so much fun. I don't know. I just felt it felt like a coming-out party. You know, the nips. The nips are out. They're here. They're. They're ready. Now that they're legal nipples! 

 [clapping at end of performance] 

HC:

This story was produced by me, H Conley. My editor was Emily Laber-Warren. Thank you so much to Chala for your openness, and honesty. And thank you for listening.