(00:04) Jess: Welcome to this episode of the Gender IQ podcast. I'm Jess Romeo. I'm a trans, psych, NP, and social worker who is on a quest to be a teacher learner about gender diversity, queerness, and how our world can more fully understand these things. And today I am talking with Brett Ford. Brett uses any pronouns and Brett is a registered dietitian here in my neck of the woods in Maryland. We have worked together a little bit so far.

Our paths have crossed clinically a little bit so far, and y'all, I did not feel like we were two clinicians having a conversation. This felt like I was talking to Mary Oliver, where we just happened to be talking about what it is to be human from the lens of queerness, disordered eating, and our body's relationship to nourishment and needs. So it made me think about Mary Oliver's wild geese, the you do not have to be good.

You do not have to walk on your knees for a hundred miles through the desert repenting. You only have to let the soft animal of your body love what it loves. And I think there's, there's so much in this conversation that is about a homecoming to our bodies, to needs, desires, and the many ways in which the world we live in tries to hide those from us or tell us that they're not okay, it's not right to have them.

So I invite you to this enlightening conversation and I hope that it gives you a little bit of freedom to let the soft animal of your body love what it loves. Well, Brett, I'm so glad to have you with us. I'm really excited about this. Just tell us a little bit about yourself, your practice, and what you do, but then I'd love to hear how things are going.

(01:53) Brett: Yeah. My name is Brett Ford. Actually, I just got married. Yeah. We were like, we should get married before the election. And so I use any pronouns. I am a registered dietitian by training. I have a master's of public health as well. my work currently kind of centers what I would say a couple different frameworks. I pull a lot from like queer feminist practice and like ecological anti-capitalism. I am an abolitionist. I think that those are kind of like the bedrock of the work that I do. And I have a small private practice called Bread and Salt Nutrition Therapy. And I work with folks where food is hard. And so some people that's like diagnosed clinical eating disorders. And for some people, they're probably in the disordered eating spectrum. And then I have a lot of clients who are trying to figure out how to manage chronic illness without maybe subscribing to a lot of like wellness culture or even like the medical industrial complex, which I know you have lots of clients who are in.

(03:11) Jess: Yeah, and it is hard to navigate that for sure.

(03:14) Brett: Sure. Yeah. So those, guess that's, yeah, that's what I do.

(03:20) Jess: Yeah. Well, it would feel weird to start anywhere, but this, since we're recording this on November 11th, 2024, how you doing after last week?

(03:31) Brett: Yeah, I would say in a real surprise to myself, I feel very confident and clear. I feel like, and it's a lot of terror. I feel really, really motivated to like, get very clear with the way that I show up in my job and the way that I show up in my community.

There's an artist, Anna Brones, who has this quote that I think about all the time, like the revolution must be fed. And so, last week and this week I've noticed in client sessions and also even just like the way that I'm feeding my family and my community. I feel like really, really, really motivated to make sure that, while the terrors of the world are often things we can't control, that like having like violence.

Nutritional adequacy is a foundation that I feel even more committed to in these times. So how are you?

(04:39) Jess: That's interesting that you feel a clarity to it. feel it. It's kind of similar for me in that. I think my nervous system is finally starting to come back online a little bit. The first few days was a mix of just overwhelming fatigue and that cortisol surge through the body that I think the only time the only other time it happened where I could really recognize it for what it was, was actually the day after the, or the Orlando pulse shooting strangely, not strangely. 

But it was a while back and I remember being at work that day with just that same energy surging and I couldn't figure out how to do my job. I couldn't pick up the phone. I couldn't decide on a task to do and I feel like I'd been stuck in there for the past few days, but a little bit of sunshine, walking around, taking a break over the weekend. I feel a little bit more together and similar, like doing similar work, working with trans and gender diverse folks. 

It just feels like "okay, the priorities are clear. We know what we're doing" and it's really helping to kind of cull away a lot of the stuff I could waste my time with. It feels really important for me to be efficient and to be in community with other people doing this.

(05:56) Brett: Yeah, yeah. I feel like it's like the punk socialist in me is like, and now we fight. Yeah, exactly. So I'm like really, it's nice to actually, I was looking forward to this conversation for lots of reasons, but I was like, yes, like I wanna be with other care workers who are just committed to making sure that people are able to be themselves and be supported in being themselves.

(06:25) Jess: Yeah. Well, I'm super glad that you're here too. Well, start off, tell us your story. Like, I'm really curious to hear how you ended up where you are doing what you're doing and

(06:37) Brett: Sure. So I would identify partially as like a third culture kid. My like first four years of life, I lived in Indonesia. And I think that the feeding practices and also just like the sense of connection to land that I witnessed from a young age was really different.

And I moved to Texas when I was four and had like, kind of like quite a lot of rupture in the way that I experienced relation and community. And I think as a white person who was living in Indonesia, there's a lot that I still reckon with about some of my history there.

But I think I really struggled and I think something that became pretty apparent to me around that time was that I was a queer person as well. And I had just moved to this place that very, very quickly I was picking up on a lot of cultural messages that like the thing that I am who I am, right? Was not okay.

I would say that like the trappings of being a white middle-class family were true in the sense that like, there was not a lot of food culture. And so I left an environment where there was a lot of food culture and a lot of ritual around food and farming and a connection to all those things. And then moving to Texas and kind of going into my family of origin whiteness and the kind of divorce from meaningful food practice in my household felt really apparent looking back.

And so there was a lot of like, you know, idealization of like the Mediterranean diet. And I was a pretty competitive athlete. I played a lot of soccer for most of my life. And I developed an eating disorder. I was probably 14, maybe a little bit younger than that when like things really started to, my behaviors became even progressively more disordered.

And I never got formally treated for eating disorder. And it kind of just ravaged a lot of my kind of young adult kind of like teenage experience. And I studied nutrition and dietetics.

And I think actually something that's important to note is that a lot of people who enter dietetics, the reason they enter dietetics is because there's already this fixation with food. And a cause that I think about quite a lot is having like, not in a gatekeeper way of like people with eating disorders shouldn't be dieticians, but of maybe thinking about having screeners for people who are interested in studying nutrition and dietetics, just to like make sure that we're supporting people who are also interested in that, because I can certainly tell you I was not alone in, I'm sure.

Like every time there's any sort of research on this, think a lot of people who are in my field are interested in nutrition and feeding are people who are also oftentimes struggling. and what was really interesting is I was like really, really struggling. And actually the thing that shifted things for me was getting a little bit more radicalized politically. And so I started, actually getting pretty interested in like community nutrition.

And so I started kind of funneling a lot of my attention. like volunteered with like Share Our Strengths, which teaches cooking skills for, I was working in Hartford, Connecticut, and then actually went to the Peace Corps in Zambia, which again, like as a neoliberal soldier is not something that I would necessarily make those same decisions now. But that was also an interesting experience in terms of eating.

And I would say that like, that is actually where a lot of my very intense eating disorder or symptomology got healed in community in this deep farming practice. Yeah. I spent a couple of years, probably five, six, doing international nutrition, focusing on maternal and child malnutrition. I worked at a couple, worked for the World Food Program and CARE.

I had another kind of like political radicalization moment and I was like, I cannot do this work. Actually, the way that I wanna do this work, I can't do this work because of some of the identities that I hold. And I kind of transitioned to policy, found that pretty frustrating and then went back to community nutrition in the United States and was working at Community of Hope, which is a really great organization that does like housing and healthcare justice in DC.

And the pandemic hit and I lost my jobs. And then what was really interesting to me is when I was working at Community of Hope, there was high levels of food insecurity. And I was also like working with a lot of starter eating. And when I had gotten my clinical license, which I had done, you know, prior to leaving for Zambia, I also did the Leland International Hunger Fellowship, if that means anything to anybody, but which was a very good.

I think another moment of like, kind of just like really looking at power analysis in a global way. yeah, and so I got really interested in this overlap of like the incidents of food insecurity and eating disorders.

And then I worked at a eating disorder center and very quickly I was like, I really want to have my own business so I can treat this condition and I can treat people who are struggling with nourishment in according to a framework that I believe in rather than someone else has predetermined for me. So there was a lot of information, but that's kind of, I think I've been orbiting around the question of hunger, whether it's like my own or a community's or the communities that I live in now and share identities with and don't. I think that's probably the through line of my career.

(13:18) Jess: Yeah, no, I see that. And I cannot help. I didn't know this part about actually being born and living for four years in Indonesia. I'd forgotten that part of your story and remember that you are from Texas, but I am fixated on that as someone who knows how powerful attachment in those first few years are for imprinting so many things.

I think that, I think that when you talk to a lot of well-meaning liberal white people, right? About whiteness. We have to deconstruct that sometimes because it's hard to identify the air that you're just breathing. And, you know, I only had the experience of growing up in Alabama and then moving to the East Coast, right? All I know is whiteness. I have never lived in a different type of culture.

And I think it sounds like something in your very bones and nervous system and attachment system was forged somewhere else, was forged outside of this structure. And I just love the full circle of you being able to maybe imperfectly and a little clunkily and through systems that have some harmful elements to them, like be able to sort of find a homecoming in ways. Like that's just what I hear in your story. Does it feel like that to you?

(14:38) Brett:  Yeah, I think a lot about how oftentimes cultural appropriation is actually just an attachment wound that whiteness gives to people in terms of just like, this is empty and hollow. This is meaningless. And I think that for me, like my interest in kind of like international kind of like quote unquote development and global health, I think it was this longing of probably something and then for a while I couldn't really verbalize it of just being like, I know that there's another way of being with each other. I know that there's another way of, like, being with the place that you oriented to. I have felt it, right? And I think that in that search for that connection and I think meaning, I was clunky, right? In terms of trying to figure it out.

But I do definitely feel like the work that I do is homecoming, certainly, in terms of just being like, what is it like to really be fed? And so I think that more than probably, I don't know, most dietitians, community practice is kind of like a core tenant of the way that I think about treating eating disorders and thinking about embodiment.

I also really think about the connection to food a little bit more than I think some dieticians would in terms of just, I think that having people having experiences of having a connection to the way that food is grown can be deeply healing too, in terms of just like working with some of the nutritionalization of food and actually like returning it back into a feeding practice.

And Angele Hangerstrong - I might have said her last name incorrectly because dyslexia is a part of my story - is a dietician who has this really cool newsletter. It's called Anti-Racist RD. And she has this really beautiful piece of like discussing why whiteness makes us so susceptible to eating disorders and disordered eating because we don't have like cultural and ritual practice to kind of even be a defense in some of our feeding practices.

(17:00) Jess: Yeah, no, that's really interesting. We'll definitely link all of these things in the notes for people to look at. So many strings to pull on, but I think I'm really interested in this through line of hunger for you and the myriad definitions I think it can have in the work that you do. Like, how was the interest in hunger over all those years?

(17:25) Brett: It's interesting, feel like all of this is, you just have a lot of links. Oftentimes when I'm reading this book, How to Tell When We Will Die, and it is by Joanna Hedva, and they're a disability justice and rights activist. And they have this thing, the definition that they work with in this book is like, what is a body, a thing that needs. And I think that I've been just kind of like, that has been circling around.

So in terms of hunger is, I think that I have just always had this real sense that they're like, I am very aware of my needs that are not met. And it feels really clear to me the needs that aren't met external to me. And in a somatic sense, it feels painful. Right? And so I think about, especially living in parts of the world where the majority of people's time is spent trying to get enough calories into their face and really like dedicating their entire lives and hours into this practice.

And then also to have. lived experience of eating disorder and to be clinically trained in treating people with eating disorder. And just thinking about this kind of paradox or seemingly paradox of like, so like, there are, there are people in this world who's like main drive, not because they want it to be because of often like colonization and like, bio political power is to just focus on getting enough food for themselves.

And then there are people in this world that their main focus is making sure that they don't have adequacy and just the drivers of that and how separate they feel. But when we take a step back, they're actually, those drivers, at least when I look at them, feel a lot more commonly rooted.

(19:36) Jess: Yeah, say more about that, about what feels like the common route to you.

(19:43) Brett: Yeah, I think we talked about this too is like, food is used politically, right? So like, sometimes I think, is like, eating, like is somebody with anorexia a response to climate change? And I think sometimes some people would say on his head, like, obviously not, but it can be, right? And like, is like, a bingeing disorder, is that somehow connected to labor rights?

And I think again, like when we look at the root of some of these conditions, they are, and so like when I think about the conceptualization of eating disorders, right, I think about all of the interesting research about how eating disorders are like not just psychiatric, how they are metabolic, right? And so like genetics and neuroscience are playing a huge role in who develops eating disorders and like they don't account for all of it. Right?

And so I think that environment is something that I think about a lot. And I think obviously in the work that both of us do in terms of the gender minority stress model.

And so I do think a lot about how a lot of eating disorders at the core of it, not for everyone, but for a lot of people, is anti-fat bias, which when you do the research, it's actually anti-blackness, right? Dr. Sabrina Strings has a whole bunch of work around fearing the black body. She has done, and I think Sonia Taylor is another leader in this kind of just very clear articulation of the fact that like, okay, so we think that we're fighting all of these different battles. And sometimes

When I look at it, oftentimes it's like, this is by experiments. 

(21:43) Jess:
Right - the same thing, different face and we're at different levels. think if it's sort of like an army, we're at different levels of knowing what the ultimate goal is of the oppressive system that we're unknowingly taking a part of. I think that makes a lot of sense. And was that Belly of the Beast, the book that you were talking about?

(22:04) Brett: 
Yeah, so, John Harrison - they're incredible. And so I think about a line that they wrote about, how, like, the, kind of essentially the, how little black boys don't get to be little black boys and, like the damage that that does. And I think the eating disorder profession has made some strides in - I would say - acknowledging the fact that eating disorders aren't just for skinny white affluent girls, right? Eating disorders, they impact everyone, of race, class, and gender, and actually they're - I would say - even more pronounced in some of the research that we have of around people who hold minority identities or identities that have been marginalized, how about that? 

(22:58) Jess: 
Yeah, I know. Yeah, and it's interesting. You make me rethink a lot of things because the conversations with you just feel like widening the aperture of my lens over and over again. And that idea of thinking about eating disorders as more than just psychiatric. I obviously, like once you say it, that feels so clear and so obvious, but I'm not as up on the research.

And so what it made me actually think of was how being a psychiatric provider, knowing that in some ways, if you widen the lens on psychiatry, we are often sort of these cultural arbiters of things that aren't fully understood yet. And it's sort of science saying, well, we don't have anything biological that we can connect, but there's something odd going on here. Why don't you just characterize that for us and come up with a treatment? And I think there are a lot of ways in which that's done harm over the years, but I mean, just on a day-to-day basis for practitioners, it's just not having a full picture of what's happening. Cause I think the, the clearest thing I can draw with eating disorders is understanding that there's a deep desire to control something and food is a lever that can be pulled in terms of trying to get control. I see a lot of overlap with OCD behaviors, right? Obsessive compulsive behaviors and other respects.

But I think that the interaction of needing control and living in a culture where the body is an apology, right? To borrow Sonia Renee Taylor's, like, I must apologize for the ways in which my body does not conform to what it's supposed to be to some standard.

(24:42) Brett: Yeah. And I think we talked about this in our first conversation, but I think a lot about like, Foucault, right? And about the need for bio power. So the need to govern the bodies of citizens and how within that there's an emphasis on kind of like, especially in contemporary Western societies on like body discipline and achieving normalcy, right? And how that actually makes like all of us so susceptible to disordered eating. And I think something that you kind of talked about is like, okay, so like, what's this obsession with control, right?

And what I find really interesting is that, like, when we look at and Cynthia Bowick, who's a researcher at UNC, she's doing lots of really incredible research, but she has this kind of understanding of specifically anorexia, but I think other eating disorders, right? And so I don't know if this would be helpful, but like eating disorders often are things like anorexia nervosa. And then we've got bulimia, eating disorder, and then avoidant restrictive food intake disorder. And then there's this kind of larger category of OSFED, right? And so other specified eating and eating disorders.

And those are things like atypical anorexia nervosa, which is every clinical indication of anorexia nervosa, but it's happening in somebody who doesn't meet the BMI requirements for being undernourished, which the fact that it's called atypical anorexia nervosa drives me nuts because it's the most common eating disorder.

(26:19) Jess
I'm gonna say it's the most - I'm normally saying, well, they don't quite meet criteria for it. So I guess I have to put atypical, but dear god, they've got everything except the bullshit BMI.

(26:30) Brett: 
Exactly. Exactly. And it's the most common one. I'm like, what is atypical about this? This is actually typical. And so, yeah, so like to kind of think about eating disorders as like this, okay, so what is this need for control? And what I find really interesting is for most people, so I think the example that I often give when I'm talking to clients is if they're, let's just say a hypothetical.

So there's like a well-meaning dietitian who goes to a middle school and is talking about, quote unquote, the obesity epidemic, and talks about things like calories and restricting certain types of foods in the pursuit of maybe a neoliberal definition of health. six of those kids, get together. They're really scared, and they're like, okay, so let's all go on this diet, because we want to make sure that these bad things don't happen to us. For five of those kids, when they take on this restrictive kind of eating practice, they're going to feel horrible.

They're going to feel like really, really increased irritability. They're going to notice their energy levels going down. They're going to have a lot of digestive distress. And most of them will then actually return back to eating normally. Statistically, one of those kids, when they get within a calorie deficit, they're actually going to feel calm. They're actually going feel like quiet.

And I think this is, you mentioned OCD, this is often where I see an overlap particularly for people who are neurodivergent in that way, and also neurodivergent in other ways of like calorie deficit, actually for some people feels like you just took an anti-anxiety medication, right? And so this metabolic kind of aberrant response to restriction, sometimes that's where it's actually not about control, right? It's just like, just, this is doing something for my nervous system and my brain.

And then the behaviors, they, and it stops becoming a choice, right? They're mental illnesses, they're not choices. especially like when you have this like measurable physiological response to restriction that is like really, I think intoxicating and very helpful for some people to move through the world. It's sometimes it starts off as a choice, I think is what I'm trying to say. And then very quickly - it's no longer a choice.

(28:56) Jess: Yeah, but even that, idea of it starting off as a choice, I don't think I'd ever thought about it being possibly social, possibly, you know, like not something that was deeply internal. I think probably because of the Haitian population that I tend to see, or I see people who are gender diverse, the story of controlling food intake to be able to control how the body looks and how the body feels, that's a story that makes a lot of sense to me.

I don't think I'd ever thought about it in that frame. So in that way, it's almost like I started my career in addiction. That's kind of how I think about people's unknown vulnerability to addiction. You don't know until the first instance. And so is it kind of like that?

(29:40) Brett: Yeah, it's definitely like that. think there are so many case studies that I could talk about, but I think about this one client that I worked with forever ago who actually got a jaw surgery and so got into calorie deficit with - unintentionally. And then all of a sudden was like, "and then once my jaw was not wired shut, I actually didn't want to eat anymore."

And I think it's things like that that I think that we all, and I do think that there's something, I mean, pathologizing people who are mad and whose brains work differently, I think, as old as time. And so I do think that especially like in the beginning of the way that people were treating eating disorders, there was often like, I'm sure you know this better than I do, but like an emphasis on like the relationship with the mother and kind of like the family system. And don't get me wrong - some of those things are present. A lot of those things are present with a lot of my clients. It's just not the only thing that's present.

(30:44) Jess:  It's not the whole story.

Brett: Yeah. And I think about, especially what's happening politically right now about the fact that what you said about like for a lot of my trans folks, so like why does disordered eating happen more for trans folks? And I would say that like the first thing is disordered eating often emerges at the onset of puberty to modulate the development of secondary sex characteristics, right? And what I find so interesting about this is that it's still always about thinness. And so for some of my trans feminine clients, like I've had some curiosity, this isn't like, I'm speaking of just generalization. So obviously there's variance within what I'm saying.

But I think that occasionally I'm like, like I would think that potentially there would be some maybe interest in like curve around quote unquote, like traditional femininity. But I would say that even for my trans feminine clients, there is a pursuit of thinness at all costs, which I think kind of links back to some of the things we were talking about in terms of like, Sean Harrison's work and Dr. Sabrina Strings. But, yeah, and so like, so first it's about making sure that the body isn't developing potentially in a way that would feel dysphoria inducing.

And then secondly, like a lot of eating disorder behaviors, they're coping mechanisms, right? And so like, I don't have to probably tell anybody listening to this podcast, the people who are gender diverse, like they experience so much bias, particularly in healthcare settings. And I think that like, it's the thing that we had talked about earlier of kind of like, oh a lot of, I have a lot of clinicians who are like, I don't work with eating disorders, but I'm a trauma therapist.

(32:35) Jess: We share a - we share a colleague I know who's like, yeah, that's a great hook for a group. Like I don't work with eating disorders, but god, yes you do. Yes you do.

(32:46) Brett: Sure, for sure. And I think that like, there's a whole anthology of kind of trauma informed eating disorder care. And in my experience, it's kind of like a little bit redundant because I, my experience of working with eating disorders is that like, trauma is almost universal for people who have eating disorders and the way that we define trauma, I think can be different.

But the other thing that I think is interesting is that I've seen an uptick in people who are using eating disorder behaviors to actually access gender affirming medical procedures. And so I would say this is very true, particularly for trans men and, you know, masculine presenting or not non-binary people. So people who are assigned female birth and kind of the BMI requirements. so like eating disorders, I think for trans folks is like within that there is control. Right? But a lot of it is actually just a response to an incredibly violent society. So like, how do I get my needs met in a world that not only is not interested in meeting them, but maybe like intentionally doesn't want them to be met.

So yeah. And I obviously hear, would also say that like, we talked a little bit about this, but like people who are gender expansive are more at risk for - of multi-level discrimination in employment and people who have food insecurity are more at risk for disordered eating behaviors. And so I think that's also a part of the mix.

(34:25) Jess: Yeah, they're all interacting. And just what you were talking about a moment ago, just to be clear, so Brett, you're talking about BMI requirements for gender affirming surgeries specifically. I've seen the same thing, actually have a few people that I can think of right now who either are or have been on a mission to lose enough weight to be able to get a consult for gender affirming surgery. the data for this, I mean,

I'm aware of the data, at least on some surgeries, that there's not really strong data that it actually impacts outcomes at all, especially for top surgery for removal, right? The top surgery removal. But those requirements are really difficult. And I think it's sometimes not even up to the surgeon, but it's based on the center where they do surgery. So it's at multiple levels of policy that are far from the patient to the point where you can't - there's no real actual way to advocate if you are a patient saying there's no data for this. Can we just not? But there's like multiple steps in the way.

(35:31) Brett: Yeah, there's actually a surgeon in Maryland, Dr. Del Coron, I think.

(35:37) Jess: Del Corral, I send everyone to him.

(35:39) Brett: Yes. Okay. was like, definitely, he wrote this, I think like op-ed recently about the fact that like there is absolutely no data that suggests this is necessary. And what I find really interesting is that like in my exploration of this topic is the logic behind it. Is it around anesthesia? But those same hospitals have zero issue putting fat bodies under anesthesia for bariatric surgery. And so if there are so many risks, then I'm a little confused.

And so I think to your point of like just patient advocacy, I had a client who I tried to advocate, right? So I'm a person who's like a fellow clinician and like have quite a lot of health literacy and was doing a little bit of advocating on my client's behalf. And it was maddening. Like I could never get contact with the actual surgeon. And then when I asked for the reasoning behind it was always just like, this is a policy. Yeah.

(36:40) Jess: Yeah, this is the policy.

(36:46) Brett: And so, yeah, it's, it's really, really frustrating. And what is to, to kind of circle back to like, there isn't data that suggests it's helpful. There's actually data that suggests it's harmful. Right? And so like -

(37:00) Jess: Of course. Yeah. Didn't mean to... god, the way I present it, of course it's harmful. I've seen people wait for so long to feel like they can navigate the world safely and in the meantime, really struggling with incredibly restrictive habits around food. it's just, it's really hard to watch people fight so hard for some bodily autonomy and on the journey to bodily autonomy, it being stripped away day by day.

(37:22) Brett: Yeah. Yeah. And in this process, you're also starving the body. And so I don't think that most surgeons that I know of, I hope, wouldn't be like, you know, a really good surgery prep thing that I've been really advocating for all my clients to do is just to like starve all of your organ systems. And then when your body is trying to heal from a major surgery, right, from wound healing to be like protein and calorie deficient. Like I don't, that makes absolutely no sense.

And so like in - and I'm sure you've seen this, I've definitely seen this in - and this is where, you know, it can get a little bit tricky from like just an ethics perspective is that I have done that work with clients in terms of medically supervising them to lose weight in order to be able to access care. I think that like intentional weight loss and the pursuit of intentional weightlessness is not a good practice for most people - I would say particularly folks with any history of disorder eating.

And I think that this is where like some of the work around like Gloria Lucas's work around harm reduction techniques for eating disorders is something that I I pull from quite a bit, but it has a lot of consequences for these people's lives. Right. And I would say in terms of exacerbating underlying mental health diagnoses. Right. So like a starved brain is a scared brain. And so then you're going into surgery and not only is your body a little bit weakened, but oftentimes you're maybe not feeling, like, quite as connected or yourself. I just, it breaks my heart in all the ways. also just makes me really, really angry.

(39:03) Jess: Yeah, no, absolutely. It's interesting to see this manifesting over and over and over again. Just the ways in which biases show up in fields that are supposedly as close to objective as one can get, and the objectivity doesn't really exist.

I just think about our implicit bias about a person or a group of people has such a huge impact on what we do with such a basic step, like what are the risks of this surgery? Right? Anti-fat bias on top of anti-trans bias, making it feel like you have to reach this high threshold to be able to say, we will give you the surgery. Yes, insurance will cover this surgery because you've been good enough in these ways. I think the history of transgender medicine in general has just been this slow slog, walking further and further away from you must meet these conventional norms, not just on gender embodiment goals, but on heterosexual sexual orientation and just the criteria that folks have had to meet to be able to even access this care. It's mind boggling and it's just so frustrating to see it continuing to show up. I guess it just - it continues to reinforce how you're drawing all these through lines and these things that you've seen in the field for so many years.

(40:35) Brett: Yeah, I think it's maddeningly frustrating. And I think a lot about like the health at every size movement, which has definitely skeletons. I think that they're going through quite a lot of transformation. They're actually doing a lot of really cool work. And I think it's better to kind of frame it as like worthy at any size. Right?

And I think that when I hear you talking about in terms of navigating like the medical industrial complex is there is this sense of like, have to perform certain things in order to be worthy of receiving certain kinds of attention. And I think a little bit about like you were talking about your experience of being in substance use, right? I there's a lot of that in terms of kind of like, okay, in order to like, there's, there's just a lot of carceral and punitive treatments in the way that you deliver care.

And I think for me, then it gets clear that like, maybe the whole system isn't really interested in actually giving care. Maybe it's always and always has been about profits. But I think even as like a consumer, right, even as somebody who has to navigate this healthcare system, it feels like I want myself and all the people I love to have a patient advocate at all time just to get the basics of like even like, you know, blood work. I think about how many times there are invasive questions asked for my clients who are gender expansive and how many times there's even a denial of care because people are performing like cis-heterosexuality or they're not even performing transness in the right way.

(42:29) Jess: Right, right. You have to perform transness in a certain way too.

(42:33) Brett: Sure.

(42:34) Jess: Well, I'm really curious to get back because I was thinking about my role as this multidisciplinary clinician, social worker, then NP, and this idea around, "I don't work with eating disorders." I know at least from being a nurse practitioner, I said that until very recently - recently when that shifted. And it was from a place of - when I really look at it now, fear... fear, but masquerading as sort of professional, um - what do I want to say - masquerading as like understanding what my lane is and where my expertise is not. Because what we were taught in nursing school about eating disorders as a psychiatric provider is that that's something you need to have had some expertise in. The person must have a full treatment team and they need to have gone inpatient or like there was some there was essentially like a number of things that had to be in place for me or many of my colleagues to feel comfortable working with someone who had an active eating disorder.

And so tell me about, I know I was able to deconstruct that only by working with someone like taking that leap and being like, okay, I like this therapist. And so I will work on this case with this therapist and then learning, the monster behind the door is really not a monster behind the door. Like I'm not going to lose my license for doing this work. This is not incredibly, you know, this is not really dangerous work. We're taking it step by step. So what would you say to folks who are in school, folks who are hearing that? Because I will tell you, that is pretty much the dominant message.

(44:17) Brett: Yeah. Yeah. I would say that not only is there not a monster behind the door, maybe it's monster, but a cute monster who needs your help. Yeah. And so, yeah, I think that oftentimes there is a concern around liability. Yeah. Right. And so I think outside of opioid disorder and use, think eating disorders have the number two in terms of psychiatric conditions that cause fatalities, right?

And so I think there is a lot of fear around death, to be perfectly honest. And I think what's unique about eating disorders, particularly with therapists, in my experience, is that if a person is underfed, oftentimes certain therapeutic modalities aren't as effective.

And so I think that occasionally, right? Like even therapists can feel frustrated about this. And so I think it's important here to talk about like ego dystonic versus ego syntonic conditions, right? And so like most eating disorders are ego syntonic in the fact that they like align with most of my clinicians value systems and kind of almost hijack them. And then it's like, this is friend. And so they're - 

(45:38) Jess: You mean your clients value systems? Got it. Got it. was going to make sure we're defining egocentonic and dystonic for folks which you are, which is great.

(45:40) Brett: Yes. Okay, good. Well, feel free to jump in and add anything that I'm missing. But I think that it's slippery to treat too, right? And so I have a lot of curiosity with people who feel afraid of working with folks with eating disorders because oftentimes it's like, "okay, so are you afraid of death? the unknown?" like, and these are things that as clinicians, we need to be facing regardless of who we're treating. you afraid of disability and debility? Like, I think there is something too about the fact that most of my clients who have been in disorder is not, but most there is because of that ego-syntonic nature, there is, I would say quite a underestimation of how sick they are. Right?

And so there's a lot, I think that can also feel tricky to work with in terms of how do I do agentic care? How can I have autonomy with, how can my client have autonomy when potentially they're compromised, right? And they're compromised by the condition that I'm trying to treat. And so I think all of those things get in the way.

And what I would say is, as somebody who's like a little bit of a nerdy birdie, like, doesn't that make you curious? doesn't that make you want to like look into that more, like get into a supervision group? And I do think that there is something to be said about having a base level of knowledge around kind of eating disorders and how they manifest in the body, how they manifest in the mind before kind of just jumping right in. And so I think that's all like clinical supervision and like, I know that, you know, Gender IQ is a great place to go.

(47:37) Jess: But like nobody wanting to be like a cowboy, right? Like go out there and just kind of practice without much impunity or caution. But I think very few people are actually at high risk of doing that when they are having these thoughts. And really it is about some pretty intense fear and being told to stay in your lane. I think especially for nurse practitioners, physicians assistants, we are often given the message that we need to stay in our lane and stay within our scope. And sometimes that message goes a little bit too deep and the fear gets a little bit too big.

(48:11) Brett: Which I mean, totally for dieticians too. You know, like as, uh, that's, that's something where it's like, "oh, are you talking about feelings? Cause like, that's, that's not your job.

(48:14) Jess: "Don't talk about feelings" - that's so funny.

(48:25) Brett: I'm trying find what their feeding relationship - if I'm not talking about like their emotions? Yeah, I think it's obviously I feel really strongly that I want people to be working with eating disorders, especially people who are interested in doing like trans affirming eating disorder care because it's so needed.

And I think the thing that I was thinking as you were talking, and I say this with like so much love for care professionals and like care professionals in general. I think that like, it's so fascinating to me because I work with clients who have been in therapy and like going to see psychiatrists and like their doctors for years and years and years. And this is the thing that they've never talked about. Right?

And I think that oftentimes clinicians themselves have relationships with food and body that are really dark and twisty and sometimes very joyful, right? And like, and I do think that oftentimes like there are things like fat bias and healthism and like all of these things that like are gonna come up when you work with people with eating disorders that don't necessarily come up when you're working with other populations at such a high level. So that's the other thing. I do think that there's -
and I say this to my clients a lot, like it's really hard to recover from an eating disorder in a world that has an eating disorder. And I think that even when I think about diet.

(49:56) Jess: That's really powerful. It's really hard to recover from an eating disorder in a world that has an eating disorder.

(50:03) Brett: Yeah. That's real. who was like kind of probably inculcated in the society we have, but also then went through programming where you are taught disordered things. Yeah. And so it's a lot of unlearning. It's messy.