A Reflection on BMI Limits
Back in March 2021 we received a google review that read:
I was denied access to care at this clinic because of my weight. I know many others have mentioned they never answer the phone, which was true for me as well. I was literally calling non-stop till I got an answer and then after getting all my private info, I was denied to book an appointment bc I'm fat. Medical discrimination at it's finest.
We take all our reviews seriously. Especially when someone is dissatisfied with our service. After receiving this review, we took the time to ask ourselves why did we have a BMI limit?
Let’s start with what BMI is. Body Mass Index is a simple calculation that considers height and weight to provide a score. It was invented 200 years ago by a Belgian mathematician named Adolphe Quetelet who was looking for a fast way to measure “the norm” in a general population. There are many problems with this calculation so let’s name a few.
Quetelet was not a doctor and said himself that the score was never meant to be a measure of an individual's health
Quetelet was working and living in Belgium, his calculations are based on White, Western European body types from bodies that existed in a different day-to-day lifestyle and different food industrial complex reality
The measurement itself gives no space for different proportions of bone, muscle and fat in the body. Meaning good strong bones and good muscle tone could actually result in a high BMI
Creating a “norm” for bodies is hugely problematic and does not account for the social, geo-political, and genetic determinants of what shapes our bodies. Norms do not determine health, nor should they determine access to care.
So why is BMI used in medicine? Mostly because of system inertia. It’s a fast calculation that’s been around for a long time. It’s problematic and our client who left the comment above is right. It is medical discrimination. Body neutral and fat liberation/positive activists, most notability black and BIPOC fat liberation activists, continue to rally against dated and systemic discrimination around BMI and fat bodies*, and delineate the ways our medical model perpetuate such systemic oppression. You can continue to read about this movement here:
https://feminisminindia.com/2020/09/01/how-did-nih-who-perpetuated-fatphobia-through-the-bmi/
https://elemental.medium.com/the-bizarre-and-racist-history-of-the-bmi-7d8dc2aa33bb
At CIHC we have a commitment to breaking down barriers to care. Sometimes that means advocating for change or supporting clients as they navigate the health care system. Other times, like today, we must examine our own policies and the barriers that are perpetuating fatphobic medical racism and outdated medical models of care. As a diverse staff group comprised of folks in various bodies, some of us who benefit from thin privilege while some of us are subject to systemic barriers as plus-size/fat bodied folks, we too are committed to thinking through this access issue.
We reviewed the latest research regarding BMI and abortion care and connected with leaders in abortion care across the USA and Canada. There does not appear to be increased surgical or sedation risk for abortions performed in the first trimester for folks who have a BMI greater than 40**. There does however appear to be increased procedural risk for folks with a BMI greater than 40 if their pregnancy is greater than 13 weeks.
We also examined our space, equipment, skills and our clinical limitations due to regulatory oversight. Clinical skills and experience are very important in care provision, and we want to ensure that all clients have access to safe abortion care. Our physicians have generally not had the opportunity to build skills in providing outpatient care for folks with BMIs higher than 40 due to the regulations and restrictions in place by the College of Physicians and Surgeons of Ontario (CPSO)***.
So, what’s the solution?
Our goal is two-fold: we will gradually increase our BMI limit and support physicians in gaining experience providing surgical procedures for bodies of diverse sizes, and we will also advocate the CPSO to address the barriers to access that result from conservative non-evidenced based regulatory oversight.
As a result of this reflection and work on our part, our new policy around body weight is that we will provide care for folks with a BMI up to 50 who require a first trimester abortion. This new policy isn’t perfect. It is still limited by its reliance on an outdated measurement that perpetuates a problematic idea of health and marginalizes fatter bodies, we know this. However, acknowledging this and implementing incremental change is a first step in our clinics’ effort to move away from a BMI-centric practice. By first pushing the BMI limit we increase access to outpatient abortion care within the community and provide our physicians (who practice abortion care in spaces outside of our clinic) the opportunity to gain the skills necessary to safely and confidently provide care to diverse bodies.
Importantly, this change also ensures that eligibility to receive care in our outpatient clinic is determined based on a comprehensive health assessment and the evaluation of whether it's appropriate is due to procedural or sedation risk, not solely weight. Referrals to hospital-based abortion settings become a response to actual evidence-supported elevated medical risk.
We also want to apologize to the clients who could not access their abortions at CIHC due to BMI alone. It was wrong and we are committed to doing better. We also want to acknowledge that even despite our efforts, barriers continue to exist at our clinic. We believe in transparency around these barriers by naming them on our site here and committing to a process of continuous improvement. Together, we will imperfectly keep challenging and thinking through access issues in abortion care and we appreciate your contributions.
* We understand that folks will have different preferences and feelings around terms such as fat bodied vs plus size vs fat folks, and that terms are constantly shifting. We use the term fat bodied in keeping with some fat liberation terminology.
** A BMI greater than 40 is considered “class 3 obesity”, and in the medical world is thought to be associated with increased health risk. We recognize the problematic and potentially triggering classification of “obesity.”
***The CPSO regulates the practice of medicine in Ontario. The CPSO provides regulatory oversight to Choice in Health Clinic. Our Clinic is evaluated by the CPSO as part of the Out of Hospital Premises Inspection Program.