This is Bad Medicine

CW: Fertility treatment, organ donation, BMI based surgical denial

Fat people are being denied fertility treatment without evidence to support it, denied organ transplants they would benefit from, and in some cases denied the chance to save a loved one's life. This episode examines the guidelines behind these decisions — and finds them cruel, discriminatory, and scientifically indefensible. This is not just bad doctors. This is bad medicine.

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Transcript

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Hello, and welcome to episode 15 of season 6 of the Fat Doctor Podcast. I am your host, Dr Asher Larmie. I've just realized that I've been giving people the wrong information over the last couple of weeks. I'm telling everyone that my book, No Weigh, is available for pre-order on the 22nd of April, and that's not true, because today is the 22nd of April, and my book is not available for pre-order until the 24th. I'm recording this in the past, so that's all things going well. Either way, by the end of this week I will have bitten the bullet, and you can order No Weigh from Amazon. If you have a problem with buying from Bezos, I'm sorry to hear that, but it is what it is.

Everything you're about to hear today, in this episode, and everything you've heard in the last 15 episodes, has been taken directly from the book, so if you've been enjoying the season, you'll enjoy the book. There were certain parts of the book that made me particularly angry, and that I really struggled to write, and this was one of them. It upset me when I was writing it, and I have to warn you in advance that it's going to upset you too. It'll be triggering. I'm going to be talking about two very important things: fertility treatment, and organ donation. These are emotionally powerful and provocative subjects, so take care of yourself. You may want to skip this one, especially if you are trying to conceive at the moment, or if you're dealing with issues surrounding organ donation. Skip it if you need to. And for those of you who are going to listen and follow along, I hope you get mad. I hope you're as angry as I am. I hope you're as devastated as I am by the end of this episode. You should be, especially if you're a healthcare professional — you should be filled with rage and shame in equal measure. Because this is disgusting. This is some disgusting shit.

I think anger is kind of the point, it's kind of why the book exists. I'm not talking about sweet and light and fluffy stuff. I'm talking about actual life and death, and that's what today's about.

So we're going to be talking about guidelines — specifically guidelines that deny fat people the right to fertility treatment and organ donation — and we're going to talk about whether that's right, and whether the guidelines hold any water. Do doctors and healthcare professionals and hospitals have the right to do what they're doing?

In an ideal world, everyone gets the best healthcare 100% of the time. That should be everyone's basic, inalienable right. But we don't live in that world. There is a gap between what we want, what we hope for, what we expect, what we aim for, and what is happening in reality. And that is the gap that doctors and hospitals and policymakers exploit. The argument they make is: resources are limited, so we have to make some hard choices. Fat people are essentially positioned as the hard choice. The treatment of fat people is a luxury that we cannot currently afford. Resources are scarce, we have to decide who has the best chance of success based on the evidence, and that's why we will deny people with a BMI over a certain number this particular treatment. So, first of all, we're going to figure out if that's true — and it isn't, so you'll be happy to know. Their justification doesn't work. But even if it were true, is it correct? Is it valid? Can we do that? On the surface it sounds very reasonable. But it isn't.

In the UK, if you have a BMI over 35, most private fertility clinics won't touch you. For an NHS clinic it has to be under 30, and over 40, forget it. There are very few clinics — I believe there's only one at the moment in the UK. And this isn't about NHS resources, because private clinics will take your money quite happily. This is just a blanket decision. In the UK, a BMI over 40 can also prevent you from fostering and adopting. So basically, what governments and organizations and policymakers have decided is that fat people who are struggling to build a family will be denied that right. You can't have fertility treatment, you can't adopt, you can't foster. Fat people are no longer entitled to help creating a family when they need it.

The justification, when it comes to fertility treatment, is that higher weight leads to poorer IVF outcomes. Except that's not what the evidence shows. There's a retrospective analysis of 308 IVF patients that looked at egg quality, pregnancy rates, implantation rates, miscarriage rates, and ectopic pregnancy rates — and there's no difference. No difference when it came to BMI. So this idea that IVF doesn't work for fat people — that's not true. It does.

There's a really good randomized controlled trial in the Netherlands, across 23 different medical centers. If you were fat and trying to get pregnant, you either did 6 months on a weight loss program and then 18 months of fertility treatment, or you did 2 years of fertility treatment. They wanted to see: does weight loss prior to IVF actually improve outcomes? And it didn't. The weight loss group had significantly fewer successful births. The fat people who just had the fertility treatment were more likely to get pregnant. This idea of, we're not going to treat you now, but if you lose weight we'll treat you — why? It doesn't work. It doesn't improve things. In fact, it makes it worse. Delaying things made things worse.

There's a paper I quote in my book by Rebecca Brown, from the Uehiro Oxford Institute. In this paper, she basically argues there is literally no evidence linking a higher BMI to reduced live births, and there's insufficient evidence that IVF is less cost-effective in fat patients. So whether you look at success rates or cost-effectiveness, there's insufficient evidence either way.

Then doctors will say, okay, fine, IVF works in fat people, but if you're fat you're more likely to have pregnancy complications, so we cannot in all good conscience help a fat person get pregnant knowing they're at risk of complications. And there are hospitals putting pressure on IVF clinics — even private ones — telling them to stop giving IVF to people with a BMI over 35 because they're at higher risk. But even if we could prove that being fat was actually the cause of that higher risk — which we can't — there are lots of reasons a person might have a higher-risk pregnancy. Weight might be one of them, but there are many others. So if you're going to argue that a BMI cut-off is in place because of the potential future risk of pregnancy complications, you must apply that to every condition that could theoretically increase that risk. Anyone with high blood pressure shouldn't be allowed to have IVF. Anyone with diabetes. Anyone with rheumatoid arthritis. But they're not automatically denied IVF. Those are individual conversations to be had between a clinician and a patient, and it's not my job to interfere in that. But blanket BMI cut-offs — that's a completely different thing. That's discrimination. Blanket exclusions are discrimination. There is no other way to describe it.

So there's no evidence supporting the cut-offs in the first place, and beyond that, it is obviously discriminatory. This isn't a situation where a doctor diagnoses you with a condition and says lose some weight. In this case, people are being denied reproductive autonomy. And that's a very different scenario. I know that there are certain parts of the world where politicians and religious leaders would like you to believe that reproductive autonomy is not a basic human right — but it is. And it sure as shit is in the UK. Doctors do not have the right to decide who gets to get pregnant and who doesn't. On a case-by-case basis they can have a conversation, they can discuss benefits and risks, but they have no right to look you in the eye and say, because you're fat, you don't have the right to get pregnant. That is blatant discrimination. It is not evidence-based. It is despicable.

So that's the life part. Now let's talk about the death part.

Kidney donations. If you're a fat person who wants to donate a kidney, tough. You've got a loved one who needs a kidney, you've got one to spare — except if you're fat, you can't do it. I tried to figure out why. I was looking for the evidence behind this and I couldn't find it. It's a well-known fact that you won't be allowed to, but the reasoning isn't clear. I found one organization's explanation — the National Kidney Registry, or similar — that basically said kidney donation is big surgery, surgery is riskier in fat people, and fat people are more likely to develop diabetes, so that's why it's not permitted.

But surgery is not more risky in fat patients. That's not true. In fact, there's actual evidence that fat people have fewer kidney complications after surgery. So if you're going to exclude anyone, you'd need to exclude underweight people, because they're the ones most at risk. And as for the diabetes argument — if you're going to deny people the right to donate their kidney based on a hypothetical future risk of diabetes, you have to deny every single person with a family history of diabetes, because diabetes is genetic, it runs in families. If that's your argument, you need a policy that says if you have a family history of diabetes, you can't donate a kidney.

The person waiting for that kidney is on dialysis several times a week. They have a significantly shortened lifespan. This is not shits and giggles, this is life or death. How dare you have a blanket policy. How dare you deny somebody the right to live based on BMI. You want to talk facts, warn them of the risks, have the conversation — have the conversation — but how dare you deny somebody the right to live based on BMI.

If you're fat, you also can't receive a kidney. You're very low on the list, sometimes not even put on the list. You're too fat. You have to lose weight before they'll let you receive a kidney. This is a person in kidney failure. There is evidence that there is only a 1% mortality difference between people of normal weight and people with a BMI of over 40. Only 1% difference in mortality. There is a 4% higher mortality rate in those who are underweight. So why aren't underweight people told they can't have a kidney unless they gain weight first? Why are underweight people not removed from the register? It's more dangerous if you're underweight. Explain that one.

Same goes for liver transplants. There's a study that showed over 70% of US liver transplant directors had formal policies restricting patients with a BMI of 40. And yet there is also evidence that people with a BMI of 40 had similar post-transplant mortality rates and similar graft failure rates to people with a normal BMI. Especially after 2007, the data is very clear — there is no difference in mortality rates. And there's also evidence that fatter people derive a greater survival benefit, and yet are equally more likely to die on the waiting list because of their weight.

I quote someone in the book who wrote an article in the Canadian Medical Journal, who basically says people with diabetes and people with hepatitis C are not excluded from the kidney transplant list, despite having comparatively poor outcomes. So if we're excluding people who have poorer outcomes, we have to do it universally. We cannot do it for some and not others, because then it's discrimination. Why are we picking on fat people specifically? Why are we using BMI — a notoriously inaccurate marker of health — to make life and death decisions? It is cruel, it is inhumane, and it is ethically indefensible.

Now here's the part that I know people are going to push back on. They're going to say I'm drawing too many connections, that I'm making it up, that I'm being hysterical. I stand by this. I will fucking die on this hill. This is the bit that keeps me up at night.

I believe that these decisions are being made specifically so that fat people will not be able to reproduce, and fat people will die quicker. I believe this is selective breeding. I believe this is eugenics. I believe this is intentional. Fat is genetic. Fat parents are more likely to have fat children — fact. So if you want to fight the so-called war on obesity, a good way to do that is to stop fat people from reproducing. That is eugenics. That is selective breeding. That is literally the definition of selective breeding.

You're going to say, whoa Ash, that's so extreme, that's such a stretch, no one's actually saying that, we would never do that. But hang on — we're already screening for all manner of medical conditions when it comes to IVF. We've already incorporated some level of selective breeding into fertility treatment. Why is it such a stretch to assume this is part of it? Why is it so shocking to think that maybe the people in charge have decided we just don't want fat people making fat babies, so let's just not let them have children? Maybe it's a subconscious thought, maybe it's intentional. But who gives — how dare anyone decide who is worthy enough, who is valuable enough, to have a child. Because this is not based on actual science or evidence. This is smoke and mirrors. Maybe it's just so that we can sell weight loss. Maybe the weight loss industry is putting pressure on fertility specialists to tell their patients to lose weight and sell their drugs. Or maybe fertility specialists look down on certain patients. Maybe they look at a patient and think, not you — you're too fat, you clearly don't take care of yourself.

I want to point out that this isn't a rogue clinic. This isn't a few doctors going off script. This is policy. This is actual policy throughout most of the modern medical world. If you're fat and struggling to get pregnant and you live in the UK, you have no options. And not only does weight loss not improve outcomes, but weight stigma and weight cycling and going on diets are going to damage your health — they're going to increase your stress levels, mess with your hormones, make fertility even less likely. A stressed-out pregnant person is higher risk. None of this is for your benefit. This isn't about caring about you and your future child. They don't care about you. Don't let them lie to you and pretend they do. There are probably lots of reasons — financial reasons, IVF clinics wanting better success rates because better success rates means more business. At the end of the day it's all about money. But don't for one second think that the reason is you, because it isn't.

I had a conversation with a doctor recently. For the first time in my life I admitted to one of my doctors: I'm terrified of you. Not you personally, because you're a great doctor, and the only reason I can tell you that I'm terrified of doctors is because you're such a great doctor and you're not like the rest of them. But I said, I don't think you understand how scary it is for me to come to this appointment. How scary it is to show up as my authentic self — because I'm fat, because I'm trans, because I'm autistic. And you people are not nice to people like me. And I know that I'm one of you, so I know what you're like, because I've seen you in the common rooms, in the canteens, after hours at work. I know what you think. I know the thoughts you have. I know the way you speak about your fat patients. I've been there. You're scary. Really scary. And you do really mean things, and you do really horrible things. And sometimes the things that you do border on — there's a fine line between medicine and eugenics, and you're skirting it, and sometimes you cross it.

Doctors shouldn't get to decide who becomes a parent based on body size. Doctors shouldn't get to decide who lives or dies based on body size. There's just no question about that. This isn't bad doctors — this is bad medicine. And this is systemic. This is policy, this is guidelines committees, this is politicians getting involved, this is insurance companies, this is the weight loss industry — it's all corrupt, it's rotten. From the top down, from the bottom up, it's rotten any way you slice it. The guardians of best practice — the people who are supposed to be making decisions in the best interest of the public — are enshrining discrimination and harm into their official recommendations.

It's all by design. That's part four of my book. You can follow the money trail and you'll see it — it's very open, very obvious, very explicit. This has never been about you. If you're a fat person listening to this, this has never been about your health. None of it. It's never been about your wellbeing. Nobody actually gives a shit if you live or die. They might pretend that they do, but they don't. If they cared about your health, they would be committed to reducing weight stigma, to giving you evidence-based treatment, to not missing a diagnosis because they're too focused on your weight. They would be committed to your basic human rights, to justice and fairness, to working ethically and without discrimination. They're not committed to any of those things.

That's the reality. That's why I'm angry, that's why I wrote this book, that's why I want you to read it and share it.

Before I stop, I want to speak directly to anyone who has listened to this and has been denied fertility treatment, who has been told to lose weight before they can adopt a child, who's been denied a transplant, or denied the chance to donate an organ. There is help, there is support, I'm here. My very good friend Nicholas Salmon is also around and has written a fantastic book for people who are fat and looking for fertility treatment. I just need you to hear right now: none of this should have happened, it was not your fault, there was no evidence supporting what doctors have done to you. The people who did this harmed you, and there is no justification for what they did.

If you are in the midst of being refused something, there are ways to challenge these decisions — and I'll put it out there, it's not easy. It requires energy, it requires you to be resourced in a way that you often aren't. You're already depleted, you've already spent all your time and energy and often money getting to where you are, and to be denied at that moment is agonizing. Weight loss feels like the simplest solution, and hey, if that's what you're planning to do, I 100% support you, I totally get it, I would probably do the same in your situation. But if you want help challenging these decisions — if you've been told you can't have surgery, or can't have this or that based on BMI alone — please get in touch.

Check out No Weigh. All of the information — the IVF data, the transplant information, the eugenics argument — it's all in the book, all with references. I'll be back next week, hopefully, and if not, the week after. Don't forget to pre-order the book. I'm so grateful for you. I'm so thankful for those of you who keep supporting me, who keep sending messages and encouragement and love. You have kept me going these last few months, and you will keep me going in the future. Thank you. Take care of yourselves, have a wonderful week, I'll see you next time.