by Albert Middle
“But what about life?”
I sank back into my apologetic trans body and shifted in my seat to connect to a different line of conversation, that my traveling companion would rather take that morning.
Two days before this chance encounter with a past Eating Disorder Consultant on London’s Underground, I had met with my current Gender Identity Consultant. I was unfazed by the usual embarrassment of bumping into someone out of environmental context, especially from a part of your life you’d rather not be on a train with.
Because I was excited to the point of bursting. I wanted tell everyone, who mattered.
“He’s approved my top surgery,” I announced with the enthusiasm of a child who’d discovered how to “Choo choo!”, in response to: “So, how are you?”
“He’s writing the referral to my chosen surgeon this week! Maybe even right now?”, I continued down the track…
A year had passed since my discharge from an inpatient admission for anorexia nervosa and two years since we, this consultant and I, had first met. Back then when my own tunnels were darker than any London underground network.
Today, the light was in my hands and I wanted them to know. Partly because it would suggest they had done good by me. I was telling them: look – I’m doing well. I am well enough in body and mind to be referred for top surgery. It meant that this long recovery had shown itself in the ways we were told it would, if we tried it. It meant…
“I am happy,” I told them.
“But what about life?”
What about life? She is right to feel (if she did indeed feel) that being trans is not the only thing about me. You could argue her approach is one of not putting the floodlights on this and for some trans experience this can feel refreshing. But in this instance, it is life, my life, and hers in this short exchange on a train. It’s a part of my trans life that I choose to bring into the conversation. And it is a piece of my life to be celebrated.
This encounter stands out because they were an integral part to me being here and able to tell them this news. Someone, whose integrity towards treating eating disorders I’d trusted, despite our bumpy ride.
But as their stop came close and so did our conversation. I was left with the feeling of ‘no change’ since our often-turbulent ward rounds. They appeared to still have no awareness that again I was being silenced, despite our shared knowledge that silence gives power to the eating disorder.
Why did their enquiry of “life” dismiss my gender affirming surgery? Why were they at ease to hear about my new writing endeavours (possibly not this one) but uncomfortable at hearing I am finally making the changes to my body that are integral to my being?
I’ve been trying to think of something that might embrace their interpretation of “life” and being in it. The closest I can come up with, is: if a past patient, who brought to the conversation that they were pregnant after years of being too unwell to conceive and achieve this integral part of their identity, would this pregnant person, be met with similar diversion?
I am not comparing pregnancy with transitioning. Rather I want to highlight how for instance, you have a friend, whom you love and are with them through their pregnancy. Now they themselves do not change – bar becoming a parent of course! But to you they are simply your friend – no different. However, no one ignores the physical and emotional changes that occur, because it IS life changing.
Well, I am not pregnant! I am a transgender person, who has been living with anorexia nervosa since childhood. It has taken just beyond as long as it has for me to get help with this mental illness, to get real understanding and actual help with gender dysphoria.
Let’s start with the illness which eventually lead me to a long and intensive inpatient admission within this NHS system.
I, like most residents in the UK, have grown up to value our healthcare. I am grateful, and loyalty makes raising concerns here complex. It is with my best intention that I do this because of the value I hold for it and because this is one system we need to trust.
The specialist Eating Disorder Unit I was placed was a place with the very best intentions. The wonderful well-meaning practitioners, however, were open only to a binary understanding of gender and therefore echoed in their treatment model, and hence arrived here, my lack of trust.
Perhaps we should begin at the top? For now, the ‘top’ of those who are directly caring for us.
A consultant’s role is intricate, and highly pressured. So too are eating disorders. I recognise that every patient in that hospital on admission, and through a large part of our treatment, we were sadly, fighting FOR our eating disorders, alongside, fighting AGAINST them.
I’m not sure I would like to be the one to make the decisions around gaging how and when you can safely begin to listen to the patients ‘demands’, their needs infact! Trusting it is not driven by the illness still. But this is the job of the consultant isn’t it? And if I was to choose this job, I’d need to understand each patient’s identity as much as their illness in order to help them, in order to have the greatest chance in recovery being found and sustained.
True treatment goes beyond the disorder. True recovery takes being able to work together. So I do believe it’s not disempowering to ask questions.
Sitting next to this particular consultant on the tube that day, I wished this were a National Rail journey instead of a local commute. Because I had a question.
I’d have liked to ask about when we sat opposite each other in those clinic rooms, because despite their understanding of anorexia it was for me most certainly a cisgendered platform I was expected to wait on.
I know my stay had its excess in challenging, not just for me, but for the staff too, and put simply – it needn’t have been.
Treatment interventions beyond initial lifesaving and metabolic stabilisation are only successful I believe with the right therapy and the right care plans. The lack of understanding led the team to be unable to support me in the way they could the other cisgender patients. They were not given trans awareness training and therefore their intuitive ability to then be able to understand what this means on a deeper level was denied. It prevented their ability to translate behaviours as well as they were able to for cis gender patients – beyond often abusive presentations and affects.
Without this knowledge they did not know what supportive words to use at the time, nor did they know how to inform me or help me access practical medical ways suitable for a trans male, not a cisgender female, to ease and assist endurance of parts of recover.
My nurses simply did not know what to do ‘when menses returned’ beyond holding my hand while I cried into a betrayal of who I am. I hid in my room for a week unable to bear it – unable to bear being seen.
It is not fair screams the child with the Choo choo train!
As I became stronger I was able to help the nurses who could handle asking… but there was a long time before when I was just too sick and would have benefited from them already knowing.
They would say I was the “first Trans person” they had on the ward.
But I knew this was not true…
“Our conversation reminds me of another patient I worked with ten years ago. They were talking like you are but we didn’t have the language for it, I’m certain now they were transgender…”, my therapist said to me in a session one day.
“What happened to them” I asked?
“I don’t know – I think for them, their way of coping was to not talk about it…”
To not talk about it? So that’s why I am talking about it now here, for them too.
I don’t know what happened to them. I do know they’d not been seen for who they are, and we are not alone in our experience.
Trans and non-binary people can feel isolated on a basic level that perhaps other patients take for granted within inpatient living.
There will be many more trans identities arriving in hospitals and needing help. I will write a separate article on this and what support is out there right now available for Clinics to access and support them in making better choices for and with us. For now, here are some of the things that need to be thought about.
The ward environment. The binary male/female bedrooms and lounge areas, the bathrooms, and the clinic rooms.
- One to ones – especially when patients need help or still keeping an eye on whilst engaging in personal care.
- Medical tests need sensitivity, one I found intensely dysphoric were ECG’s
- How patients, members of the community are addressed, correct and respected pronouns.
- The admission and assessment forms, hospital notes added on the JADE patient record system.
It’s important that we do not feel we are asking something that is a ‘problem’ – ‘I am a problem for you to accommodate.’
Individual therapy and group therapeutic sessions need to be thought about also to enable them to be run more sensitively:
- One’s focused on physical and biological health in relation to current states of health and the changes through weight restoration.
- Discussion around hormones, menstrual cycles, bone densities, age, length of illness, other health conditions as a result of the eating disorders all have impacts in relation to different bodies and identities.
- Work on and around body positivity and accepting your new healthy and changed body. Lives and experiences that might be different to the majority of the group need to feel safe enough to be expressed…to enable them to be supported.
- Individual therapist need an understanding of gender dysphoria and gender variant identity to provide a safe space and a positive experience in a therapy setting for trans people.
In my case once I’d reached a weight where feelings around identity returned I was allowed to attend sessions outside with a Psychosexual Therapist to help me explore this, whilst remaining an inpatient to keep me safe and to continue gaining.
This specialist work led directly to some mentoring from a trans male health care worker at the adjoining clinic for Trans people.
However, my pathway was conflicted. In these sessions, I was receiving support and comfort around acceptance of my identity and talking about making changes to my body to bring greater feeling of congruence with this identity, which was positive and affirming. Only to then return to a program focused on learning to recognise body dysmorphia and the treatment model here was to work toward acceptance of this body.
Trans is an umbrella term and the steps in regard to transitioning will be different for each individual. For many, including myself, this involves medical support, beginning with hormone therapy. This treatment will influence eating disorder treatment and vice versa. Therefore, working with and alongside Gender Identity clinics (GIC’s) – a dual treatment model/plan and communication between the two is vital.
I am a gender queer trans man, who during my time as an inpatient had not yet medically transitioned. My team needed to be aware of the kind of thoughts and risky coping, self-hatred behaviours that may be triggered when the inevitable changes to my body occurred. Prevention is far better than treatment in any scenario. It is vital that staff understand the risks of this ‘first transition’
I say first transition, not to dilute anyone else’s recovery journey but to highlight there are two trains traveling with heavy loads – and we need an anti-collision device. Almost always with the single journey, there is a sense of return, which is also a welcome recovery drive! To return to family, to children, to parents, to other caring roles, to college, to university to work, paid and voluntary, and the rest; to return to life…to return to YOU.
Sometimes loved ones would implore
“Please bring her back to us”.
Almost always it was “she”.
But what if you are not returning? Because returning is wrong. What if ‘returning’ is just the first part. Because the transition you need cannot even begin until you are out of the grips of anorexia. So first you must return to a person that is forced to sitting in the middle of wellness, maintaining and trying your best to “present” as how you feel inside, in a body that is now a thousand times further from this being successfully felt in your own authenticity, and equally being successfully seen by others. Again, this is something Ash Thoms touches on in their above article.
Excitement rises towards any discharge along with fear, anxiety, relief and hope. Discharge day is our beginning of truly returning, and taking those first steps into that future plan we have been working on. I stepped outside those hospital doors and people would ask,
“Can I help you miss?”
When I was growing up and before puberty, in the late 80’s most people addressed me as a ‘boy’ and so I felt like me. My brother would get angry when this happened. To him I was being wrongly identified, and would tell them to “shut up” and that “SHE IS A GIRL, STUPID”
I would tell him that, “I didn’t mind” and secretly felt proud of those moments kicked out of ladies toilets and changing rooms.
Later years were identified as androgynous. Clothing helped a little with the gender dysphoria (when I had a choice about clothing) Hidden in baggy everything, to conceal my form from them and so I didn’t have to feel it against my skin in me.
In my adult years, it was not that I was never called ‘she’ or received as ‘female’ – puberty put a stop to that freedom.
No, it was deeper than this. By now I had taken the only control I imagine I could back then and for most of my life it would become – I was now living in a body that felt nothing.
Neither did I miss a gender I did not feel to have, nor was I tormented by being in one I am not.
Through the dramatic weight gain unavoidable under inpatient admission the process of feeling both these within myself within a year, paradoxically a short space of time for your body to go through such a dramatic transformation. I am reminded how the system let me down.
Being trans and anorexic and living within this cisgendered recovery model felt insurmountable at times. You end up not only fighting your battle with yourself each moment of the day. You then alongside this, must fight as your own advocate to be heard. Hearing beyond a binary idea of “my fears of becoming a woman because I have fears of becoming an adult”, my consultant said to me when I could not bear what was happening with my body.
In 2018, this really is something eating disorder consultants need to be on point with.
Now, not understanding, is still an action, and sometimes in resort to, there is another action.
To end this account, what followed mine, was his, (as he identified.)
I returned from A&E and a locum doctor had arrived on the ward.
He came and sat on my bed and he asked me to talk to him. He said some other stuff, but what I remember most of all,
“My door is open”
And it was.
It stayed that way for the rest of my admission and we began to work on a surrogate plan. He helped me to make peace somehow with my body – not entirely, but “there is another way” he said.
His action – because he had awareness and experience I later found out. After all this time, within the first week of us meeting, we sat together and wrote to a GIC my referral.
“They can give you the help you need, the help you deserve,” he gave me.
and I’m happy to be able to report to you, that they are…
Fortunately, for other transgender patients and my companion consultant, should they choose to alight here. This train to recovery we are all on now have stations that supply bespoke and practice based trans and gender variant awareness training.
Watch this GAP!