Gender-Inclusive Residential Treatment: Breaking the Treatment Binary

Although this is an essay, allow me to start as I do in all my presentations, by listing my privileges:

I am a white, straight, cisgender, allosexual, mostly able-bodied, mostly neurotypical, financially stable, well-educated person. These are all things that have made it much more possible for me to be where I am in life today – working at a job I love, being able to attend and present at conferences, and being respected by a community of peers that I wholeheartedly admire.

For the past six months, my greatest privilege has been being the lead therapist at Carolina House’s newest six-bed residential treatment house, The Estate.

There are so many things that make our new residence special, but the one upon which all else are built is this: The Estate is a fully gender-inclusive house. Wherever someone falls along the gender spectrum, they are welcome here.

I, along with many others at Carolina House, recognized a true lack of eating disorder treatment for the transgender community. Trans folx are so often left behind in the eating disorder community, and very often are misunderstood. There is precious little research out there for helping trans folx.

Trust me, I know. I’ve looked desperately for any kind of research I could find, as I sat with people who were struggling with the twin challenges of intense body dysmorphia driven by an eating disorder and intense gender dysphoria. These individuals were living with the absolute knowledge that the gender they were assigned at birth was not at all who they were, and that the body they had didn’t fit who they were.

There aren’t many support groups either. Trans Folx Fighting Eating Disorders (TFFED) is pretty much the only organization working to help this entire community. They, of course, are a dramatically understaffed nonprofit organization with limited resources to help. And, of course, as trans folx encounter other areas of oppression in their life – for instance, having an eating disorder – they also have access to fewer and fewer resources.

I came into my work at The Estate with all of this knowledge hanging out in my head, with the reality that I will never fully understand the lives and struggles of transgender individuals, and with the hope that we could offer a safe place for healing. I have absolutely loved watching that come together.

The Estate always has a small community. It’s a peaceful place. There is room for both joy and sorrow here. I have seen people who have otherwise never felt safe or supported find these qualities at The Estate.

And perhaps the coolest part of all of this is that the groups are mixed gatherings of people united in their struggle against an eating disorder. Some who heal at The Estate are cis women, some are transgender men. Some are gender-nonconforming individuals, others are cis men.

And as I watch this happen, I truly cannot believe how great my privilege is. I have the privilege of observing, learning, and finding avenues of commonality. Treatment for eating disorders is so often broken into specific categories, such as all-women or all-men (and pretty much never trans folx, especially if they haven’t had gender affirmation surgery and a legal name change). Being a part of breaking that binary open is amazing.

I still have so much to learn about caring for folx in the trans community, but here is a short list of (some of) what I know so far, and what anyone coming to Carolina House can expect:

  1. Ask for, and then use, a person’s pronouns! Never make an assumption based on name or appearance.
  2. Even if someone hasn’t had their name legally changed, never deadname them. (“Deadnaming” means using the name they were given at birth that went along with the gender that was assigned at birth). Don’t do this out loud or in documentation. Don’t do it at all – it’s abusive.
  3. Don’t make assumptions about what a person wants in terms of transition. Some people want top and bottom gender affirmation surgery, but a lot don’t. Some people feel great using transitional garments. Some use hormones, others don’t. Always remember that genitals don’t make a person who they are.
  4. Don’t conflate gender identity and sexual orientation. Someone can be both transgender and heterosexual, I promise you.
  5. Ask about how their eating disorder interacts with their gender identity. Sometimes the two are extraordinarily interconnected, and sometimes they aren’t related at all.
  6. Take gender out of your group materials as much as possible, and weed out materials that are overly tied to any gender or gender expression.
  7. Center lived experiences and own voices. My experience as a fat cis woman is entirely different from the experience of a fat trans woman or someone who is gender-nonconforming. In this work, I always center their experience.
  8. Remember that while someone who is transgender is coming into the room with a lot of possible lived trauma and rejection, you are still working with, first and foremost, a human being. People are people and deserve to be respected and validated.
  9. Lead with compassion. Always.

Remember the most important oath of being a medical caretaker: First, do no harm. Placing patriarchal, cissexist views in the middle of treatment is only going to harm everyone.