This story was originally reported by Gabriella Gladney by The 19th, and republished via Newsgroup rewiring‘s partnership with the 19th News Network.
When Elie Liakopoulos discovered she was pregnant, she immediately knew she wanted an abortion. A surgical abortion to be precise: a previous painful miscarriage experience made her hesitant to take the abortion pill at home, because both miscarriage and abortion are treated with medication using mifepristone. She lived in Portland, Oregon, where access to abortion is legally protected by the state. She assumed this would be the hardest part of the process: scheduling the appointment. She called the Lilith Clinic – an independent abortion provider in the city – completed the intake process and set her date.
Then a phone call changed the course of her plans.
“They called me back to tell me they wouldn’t be able to perform the abortion. I had no idea at the time that you could be turned away from an abortion for any reason, regardless of the extent,” Liakopoulos said. “They just said they had a BMI limit.”
Body mass index (BMI) is a screening tool to estimate a patient’s body fat. Patients above a certain BMI seeking a surgical abortion may face significant restrictions and delays (however, medical abortions are not affected by BMI). These barriers can lead to a struggle to find alternative care, leaving patients with persistent frustration, physical discomfort, and emotional distress.
The Lilith Clinic said that while they could not comment directly on Liakopoulos’ experience, citing healthcare privacy laws, its policy was to “assess each patient from an anesthesia perspective, as well as a gynecological perspective, to see if he or she was a candidate for a safe outpatient procedure,” and to refer them to a hospital if they felt it was necessary.
For Liakopoulos, the denial meant she would have to stay pregnant longer, putting her in the twelfth week of her first trimester.
“My first trimester was marred by horrible morning sickness that lasted all day,” Liakopoulos said. “It was really terrible not being able to eat or smell anything for another week and a half.”
She eventually received care at Planned Parenthood Columbia Willamette, a location in northeast Portland. But her body size also shaped her experience there.
“They did not sedate me like they told me they would, nor did they manage my pain like they did during my last abortion procedure,” Liakopoulos said. “They said this was because my neck was larger than 18 inches and because my BMI is high.”
Planned Parenthood Columbia Willamette does not comment on individual patient experiences, but a spokesperson did say, “The anesthesia and sedation policy is based on evidence-based medical standards and designed to ensure patient safety. Physicians assess each patient’s health needs, including factors such as BMI.”
Her previous surgical abortion at a similar stage of pregnancy had been painful but short-lived. This time, she said, she cried. The difference in anesthesia allowed her to feel much of the procedure.
“My abortion was noticeably much worse, materially, much worse, because of my BMI,” she said. “The difference that three years of getting a little fatter made.”
Size as proxy
There are no comprehensive statistics on how often patients are denied a surgical abortion because of BMI or body size. Obesity is typically defined in medical research as a BMI of 30 or higher, but studies consistently show that abortion is safe across all weight categories. In medical abortions, BMI does not affect dosage or successful outcomes.
“Physiologically, there is nothing that should stop you from performing these safe procedures or medications,” says Dr. Noora Siddiqui, a family physician in Philadelphia and fellow at Physicians for Reproductive Health.
She added: “Strictly from a clinical point of view there is no difference in outcomes for someone above a BMI of 30 and someone below a BMI of 30.”
Recent research supports that. A Study from 2025 published in the magazine Obstetrics and Gynaecology found that obesity was not associated with an increased risk of complications from surgical abortion, even when age, gestational age, and previous cesarean delivery were taken into account.
One earlier Study from 2019 in Perspectives on sexual and reproductive health found that the rate of complications did not differ by BMI, but that patients with higher BMI were more likely to be referred from the clinic, often resulting in delays and higher out-of-pocket costs.
Still, BMI limits act as a proxy for other concerns. Clinics may turn away obese patients seeking abortions due to a lack of training or equipment, experts say.
“The history behind BMI was based on white, Scandinavian, European men,” she said. “It is not designed to guide medical management.”
Siddiqui mentioned anesthesia as an example. Some anesthesia providers rely on insurance policies or older risk models that consider BMI a disqualification, even when evidence shows moderate sedation is safe.
“If the person providing sedation is not educated or trained in the care of higher weight individuals, it creates bias,” Siddiqui said.
Another common reason is equipment.
“That could be the bed someone lies on, or the chairs someone is supposed to sit in,” said Meghan Daniel, senior program director at the Chicago Abortion Fund, the nation’s largest abortion fund. “Whether or not the literal physical structure of the clinic is made to house their physical bodies.”
Siddiqui said BMI restrictions are not without consequences.
“If we use these numbers to prevent people from getting essential, safe and time-sensitive care, we are causing delays,” she said. “We are causing increasing costs such as travel, childcare, loss of work or income.”
Lexis Dotson-Dufault had an abortion years ago while in college in Massachusetts. Access was easy, even if it was emotionally difficult. Medicaid paid the costs. The visit to the clinic itself, she said, was the easiest part.
Years later, while living in California and working in reproductive justice, Lexis discovered she was pregnant again.
“I knew right away that I wanted a surgical abortion,” she said. “I just wanted to be quick, in and out, done.”
She made an appointment at FPA Women’s Health in Long Beach, where she previously went for routine care. She took time off work and flew her best friend in from across the country because she needed someone to drive her home after the anesthesia.
During the appointment, a nurse came back to the room after the ultrasound.
“She was like, we can’t do it today,” Dotson-Dufault said. “We have a visiting doctor and he is not comfortable performing a surgical abortion on you because of your BMI.”
When Dotson-Dufault asked if the regular doctor could perform the procedure later, the nurse left and returned.
“She just hands me a bunch of different papers with different hospitals on them,” Dotson-Dufault said. “I immediately black out. I think: What are you giving me?”
She said she was later told that the denial was not about the visiting doctor, but that it was part of their policy.
When asked for comment, FPA Women’s Health pointed to their guidelines on their website, which state that individuals with a BMI over 60 are considered high risk and will be referred to hospitals for their safety. Dotson-Dufault says her BMI at the time was 53.
“I didn’t expect this in abortion care because abortion has so little risk and is so safe,” Dotson-Dufault said. “All you looked at was my weight and said, ‘That’s not OK.'”
Barriers to healthcare
Abortion services are one area where size-based barriers emerge, but not the only one.
“The fatter I’ve gotten, the worse my care has gotten,” Liakopoulos said. “My fatness says nothing about my health.”
Christina Hughes, a size-inclusive doula who runs their company Big Fat Pregnancy out of Seattle, said these experiences mirror what many fat patients encounter during pregnancy and reproductive care.
“We start out at a disadvantage with chairs that press against us, dresses that aren’t big enough, tables that don’t fit our bodies,” she said. “We feel physically uncomfortable and mentally we are seen as not enough.”
They added that fear and shame determine how patients experience care.
“When we fear that our body can’t do it, can’t have a baby, can’t be a parent, we’re already physiologically signaling to our body that we can’t do this,” they said.
That fear can make it harder for patients to ask questions or stand up for themselves when they are denied care.
Abortion funds help patients connect with healthcare providers and coordinate care. Some work to act as a buffer for patients by identifying the clinic’s limitations in advance. Daniel said the Chicago Abortion Fund conducts research at clinics on BMI limits, equipment limitations and sedation policies so that callers are referred to providers who can meet their needs. She said that among the dozens of clinics surveyed, a handful explicitly said they had restrictions on who they could help.
“Everything we do is guided by our callers,” Daniel said. “We want to make sure that the place where they receive abortion care really suits them best.”
Siddiqui said broader change requires education and accountability from providers.
“There should be more education about this, and more research done for all body sizes,” she said. “Safe, accessible and effective reproductive care.”
Liakopoulos said what she wants is simpler.
“I just want fat people to be included. Fat people make up more than a third of this country. If we’re all treated worse simply because our bodies are bigger, that’s clearly a systemic problem,” she said. “If access to abortion requires kicking a few fat people off the medical table, I think in the grand scheme of things, people think it’s worth it. And you know, being in that statistical ballpark is not a fun place to be.”
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