Updated: Aug 24
Our guest writer Thokozani Mbwana reflects on the internal and external challenges faced on their journey through gender affirming surgery - exploring dysphoria and intersectional stigma at the heart of the health care system.
"Oh! To be black, fat-bodied and agender:
Tales from top surgery."
by Thokozani Mbwana
I can’t remember exactly when dysphoria entered my life. Initially, it would come and go as a hazy fog, sometimes lifting briefly to allow me to see the horizon beyond, sometimes so thick that it would travel to the back of my throat and press down on my lungs- suffocating and oppressive. Over the years, the fog settled into my chest more and more, nestling between my organs and refusing to leave. Every day I would wake with a burning sensation in my breasts, and as time went on, the constant feeling that I was finding it harder and harder to breathe.
It’s taken me about ten years to reach my current place of being - the fact that I am agender. It has mostly been a journey of ‘what ifs’ and ‘what could bes’, ten years of self interrogation - ten years of hoping for a more bearable life path to reveal itself. But as the burning in my chest only grew stronger and my breathing grew fainter, one day I realised that if I did not choose to live in my truest form, I would spend a lifetime in a constant state of despair.
''I had to come to terms with the fact that with the limited language and expression we have around gender, that though I envied men who had flat chests for their ease of their gender, more specifically what I desired was the aesthetic of a flat chest in relation to my own identity.''
Agender to me is to transcend the binary, existing completely outside of the rules and regulations of gender and its conditioning. I’ve had to learn to do away with my own ideas of and subscriptions to gender. I no longer think of myself in binaries of masculine or feminine because my identity, by definition cannot be ascribed such things. But that has not meant that my processing hasn’t been binary or that the way I’m perceived isn’t either.
I have long since understood that as a fat-bodied, hip-heavy “baby-faced” person that regardless of my expression or aesthetics that I will, nine times out of ten- without effort, be read as some variation of “femme” and/ or “woman”. For a long time, I really struggled with this social reality, especially when in my personal reality I do not perceive myself in that way. As time went on and I explored the intersections between my bisexuality and my ever evolving (un)gender identity, I realised that a lot of my desire for men was rooted in gender envy and not sexual attraction. I had to come to terms with the fact that with the limited language and expression we have around gender, that though I envied men who had flat chests for their ease of their gender, more specifically what I desired was the aesthetic of a flat chest in relation to my own identity. Though my gender envy manifested as “I want to be him” it was not man-ness or masculinity that I was aligned with, but rather how I perceived myself to be in my mind's eye which was that “Breasts do not serve my perceptions of myself in relation to my gender identity.”
''As black, fat-bodied and agender in the medical system trying to access gender affirming surgery - it was crucial that I interrogated my own internalised fatphobia before what I knew would be a war against my body.''
But we all know, in uncovering one thing, there is a well of other interlinking factors that reveal themselves. On my journey to understanding myself and my desires for my own body, I realised that in all my imaginings of my breast-less self, I was incredibly thin. I could not imagine myself outside of thinness because my internalised fatphobia dictated that because I was fat and “curvy” I could not or would not- regardless of whether I had breasts, be perceived outside of “femme”. I noticed the pressure for the archetypical “androgynous nonbinary” building up inside me- leading to more rounds of self-reflection and interrogation about the incessant conditioning of gender binarism. This was an incredibly difficult and necessary journey to embark on that came at the right time when, in early 2021 I started seriously considering top surgery. As black, fat-bodied and agender in the medical system trying to access gender affirming surgery- it was crucial that I interrogated my own internalised fatphobia before what I knew would be a war against my body.
''I could’ve really gone into the anti-black and violent origins of the BMI system, but I knew that arguing with a certified doctor about how exclusionary and violent that thinking and practice was, would do no good for my mental health.''
I explored both the private and public health options for top surgery to get a better understanding of what would be available and doable for me. I still remember the hours I waited to meet the doctor at the public hospital, who sat across from me for less than five minutes before very matter of factly stating that I could not, at all, access top surgery in the public healthcare system in my city. Because one of the requirements for surgery was for me to have a BMI (body mass index) of 25, she explained that she could already see that I was ineligible. I could’ve really gone into the anti-black and violent origins of the BMI system, but I knew that arguing with a certified doctor about how exclusionary and violent that thinking and practice was, would do no good for my mental health and so I shrugged it off and tried to move on.
Some time later, I sat nervously in the private doctor’s office. This man would turn out to be my surgeon a few months later. I came into his office with a booklet of questions - the first asking about weight and surgery. His response was the same- you have a better chance of survival and better healing results with a BMI of 25,“But, I’ve operated on patients bigger than you and they were just fine. I understand the urgency of gender affirming surgery and your weight won’t be a barrier to you accessing this surgery.” Of course my weight wouldn’t be a barrier if I was paying out of pocket. I tried to be reassured by what he said and as I was packing my things, I resolved to take what he said positively. As I turned to leave his office right after that thought- he suggested I lose weight anyway.
''I was yet again reminded of the uncomfortable complexities of being fat, black and trans in the healthcare system. My pain - a nonfactor. My concerns - dismissed.''
I spent the next few months before my surgery doing research, with results of fat, black folks experiences being few and far between. Regardless, I felt I had done all I could to prepare myself emotionally, physically and mentally for the journey ahead. But, things never really work out the way we plan or hope for.
After surgery, my drains stayed in for three weeks, which is at least two weeks longer than usual. I had accepted long before this that I would leave surgery with “dog ears'' (fat pockets left on the sides of your chest to ensure the skin doesn't tighten too much during healing- typically only done on fat patients) but what I could not stand was the pinching pain and swelling I was experiencing at the site of my drain ports. I became increasingly distressed at every weekly post surgery check-up when trying to explain to the doctor how these drains were not at all suited for my fat body, and how excruciating the pain from the swelling of my fat rolls were, because they sat right above the ports. Crying in his office in pain as he refused to prescribe me any painkillers because “the pain really isn't that bad '' I was yet again reminded of the uncomfortable complexities of being fat, black and trans in the healthcare system. My pain - a nonfactor. My concerns - dismissed. Later on in one of my check-ups I would in fact find out that one of my nipples became necrotic and died because of the lack of blood flow.
''Do I think if I was thin and white this journey would have been different? Yes, absolutely.''
I try not to be bitter about some parts of my top surgery journey. I can say unequivocally that it wasn’t an easy journey, holding a beautiful body I loved and hoped the best for, and presenting it to people who brazenly suggested that it was not worthy of the future it deserved. Though the bitterness lingers and sometimes I try to fight it- I do believe that experiencing such difficult feelings has helped me process a lot of what I had thought was unprocessable. An incredible support system who reminded me every step of the way how precious my body and I are were important. My therapist talking me down from disordered eating episodes was important. Discarding binary ideas of fat distribution and body types was important. Talking to my body every day and praising it for surviving such a tough transition was so incredibly important.
Do I think if I was thin and white this journey would have been different? Yes, absolutely. But at what cost does desiring being thin and white take away from the phenomenally empowering experience of choosing my agender final form in all my fat, black glory? In the end, I am exactly as I am meant to be.
About Thokozani Mbwana (they/he):
Thokozani is a nosey researcher by day and an Ancestor-summoning poet/writer by night. Their work explores existing and becoming and the murky confusion in between. Find their debut poetry chapbook The Sunflower Faces East At Dawn here and personal essays chapbook Agender Daydreams here
Connect with Thokozani: