I used to feel fat.

I don’t know normal. So when I’m told that this feeling is “fat” I believe them.

I don’t remember the exact moment someone first suggested I start dieting, but I know my mother had already been doing it religiously for nearly two decades. In high school, she was on Weight Watchers, eating as little as 900 calories a day, desperately trying not to have the body of her own mother.

Grandma had a fridge full of strawberry jam made with artificial sweetener stored in reused light cottage cheese containers, and a magnet on her fridge in the shape of a tutu’d hippo saying, “A moment on the lips, forever on the hips.”

So when I’m told this uncomfortable feeling should be met with a diet, I believe them.

We eat the cabbage soup diet. I’ve heard it was first designed as a crash diet plan for people who “needed” to lose an exceptional amount of weight before undergoing heart surgery. I have no idea if this is true.

Day One: as much cabbage soup as you want (none), as much fruit as desired, but no bananas.

Day Two: as much cabbage soup as you want (a bowl for lunch, a bowl for dinner), all-you-can-eat non-starchy vegetables, and one baked potato with butter as a reward.

Day Four: As much cabbage soup as you want (I’m so hungry, please give me seconds, and thirds), all the skim milk and bananas.

Day Six: as much cabbage soup as you want (I cannot eat another bite of this without gagging), unlimited non-starchy vegetables and beef.

I was nine years old.

The crash diets and weird fads lasted more than twenty years. Classics like Atkins and Weight Watchers, Paleo and Keto. Strange gimmicks like this set of smelly marker-shaped devices in green apple, black licorice, vanilla and cherry, ostensibly designed to curb cravings. With every diet, I gained more weight. (Twice in my life I have lost more than 100 pounds, shortly after each loss reaching my highest weight ever.)

You may be familiar with a common refrain in fat-positive and fat liberation spaces: “Fat is not a feeling.” As author and podcaster Aubrey Gordon writes:

And I admit that I’m sure there was some of this in what I was expressing. I learned that being fat was one of the worst things I could be very early on.

But my experience was also more complicated. I was (or at least am now) fat. And I felt an extreme, “clinically significant” discomfort with my own body. Now I can locate that discomfort in words like “dysphoria” or “gender incongruence” but at the time, the only reason I had for that feeling, what I had been told over and over again should make me uncomfortable, was the specter of potential fatness.

Queer and trans people are at a significantly higher risk for disordered eating. Transfeminine people often face increased scrutiny of their body size when they begin to be read as women, and larger transfem folk may find it harder to find appropriate, affirming clothing. Transmasculine people frequently use restriction or exercise to try to control what they or others perceive as a “womanly” shape to their hips, thighs, or chest, and also often struggle to find clothes that both match gender identity and actually fit their bodies.

And fat transgender people face double stigma. We are often denied care as a result of our body size, or are forced to engage in intentional weight loss in order to access necessary care, despite a lack of evidence to support this.

“The gatekeeping is just really frustrating because it’s not particularly evidence-based. Clearly,” says Dr. Megan Riddle, MD, PhD, the Medical Director for both ERC Pathlight centers in Bellevue and Seattle, Washington. “We do surgery on people in larger bodies all the time. If it’s bariatric surgery, right? No weight limit on that.” I can speak to this from experience, having been offered weight loss surgery in order to lose enough weight to “qualify” for top surgery with particular surgeons.

Those of us who have a history of disordered eating are at particular risk for relapse when we face weight-related gatekeeping of necessary medical care. Rachel Millner, a psychologist, Certified Eating Disorder Specialist and Supervisor, and Certified Body Trust® provider, works hard to push back against that gatekeeping. “Usually if it’s around surgery, it’s because of anesthesia.” Pushing back often looks like expressly questioning this apparent hypocrisy. “What if this person wanted to have bariatric surgery? Are you concerned about the anesthesia then?” she has been known to ask providers. “Well, isn’t anesthesia the same no matter what surgery you’re doing?”

Millner specializes in treating “atypical anorexia” i.e. anorexic behavior in someone whose body weight is not considered dangerously low, particularly in fat people. (Despite popular beliefs that associate only binge eating with fat bodies, very eating disorder found in low-weight populations can also be found among fat people.) Unfortunately, sometimes this means trying to figure out ways that her clients can engage in the intentional weight loss being forced on them by endocrinologists or surgeons in order to access life-saving transition care, while trying as best they can to avoid triggering relapse.

Talking about Body Trust and Health at Every Size to health and wellness professionals can be risky. I feel it as I’m writing this, the possibility that I might alienate or infuriate my readers by suggesting that the health of fat people may be more complicated than “common sense” suggests. That I may lose readers and supporters by writing about the fact that every negative consequence currently associated with being fat is also associated with both medical weight stigma and restrictive dieting that leads to weight cycling.

What I know is that nothing I have tried, in more than thirty years of trying, has allowed me to change myself from a fat person to someone who isn’t fat. What I know is that I was only able to get in touch with my body and identify my gender dysphoria after vowing to give up dieting and learn to trust my own somatic experience of the world.

When I gave up the idea of “feeling fat” and accepted myself as being fat, I was able to put words to how and where I was actually feeling discomfort, was able to discover what I needed to stop feeling that way—namely, testosterone therapy and top surgery. I still had to fight an endocrinologist who constantly pestered me about losing weight. I still had to search long and hard for a surgeon with experience operating on fat bodies. But I had the information I needed to advocate for myself.

And as a result, as expected based on the literature in support of gender-affirming care, virtually every aspect of my mental and physical health has improved.

This isn't just my story—it's the story of every fat trans person forced to lose weight before accessing care, every individual whose authentic self gets buried under decades of diet culture messaging.

We need systematic change: surgical protocols that account for and address actual risk rather than arbitrary BMI cutoffs, endocrinologists trained to recognize the difference between metabolic ill health and their own weight stigma, and mental health providers who understand that "feeling fat" might be code for something else entirely.

It turns out, letting people be who they are saves lives. It saved mine. It could save so many more. We need institutions willing to act on that knowledge, instead of hiding behind outdated policies that prioritize weight loss over wellness.