By Pallavi Basu, MS4
As with all writing published on Stories in Medicine, locations and names in this piece have been changed.
“Ready for your first admission?”
Scott, my senior resident, interrupts the monotony of fervent typing in the workroom. Like all unassuming long call days, a torrent of admissions will inevitably follow; my team steels itself in preparation. But it is my second day as a medicine sub-intern, and the novelty of having my “own” patients is still exciting. In indecipherable shorthand, I note the history Scott recites: “Mid-forties, HIV-positive, male-to-female transgender veteran, recently treated for chlamydia, presenting with fever and flank pain.” He looks up. “Interesting patient – great for a medical student.”
What renders her interesting? Perhaps he refers to her broad differential diagnosis, a reprieve from the cirrhosis and heart failure exacerbations predominating our service. Maybe he means the challenge of interacting sensitively with a transgender patient – a member of a historically vulnerable patient population – a task for which medical schools often ill prepare students.
Walking to the ED, I recall a late afternoon stroll years ago with my grandmother in India. She’d paused to seek blessings from an eloquent, ornately dressed woman seated proudly amongst her belongings beneath a bodhi tree. My ten-year-old self had stared, fascinated; who was this lady my grandmother treated so reverently? I learned later she was part of the hijra, a three thousand year-old community of transgender women perceived to be in communion with goddesses in the Hindu Ramayana. Yet these “goddesses,” who centuries ago graced royal councils and blessed newborns, became criminalized during colonial rule simply for their identity. How did they see themselves amidst such branding?
I knock on the sliding glass door. Louise – her preferred name – looks up suspiciously, her hands moving restlessly around threadbare blankets. The smell of stale smoke, unruly blonde wig positioned slightly askew, and shiny tear tracks paint a picture of misery. I pull over a chair and introduce myself, apologizing for her obvious distress and rubbing her shoulder. She appears taken aback by the simple gestures and haltingly answers my questions. As I take a sexual history, her hopelessness becomes especially prominent.
“Do I have chlamydia again?” Her eyes water once again. Without meeting my gaze, she flatly informs me, “no one wants to touch me anyway.”
I sense her anguish and don’t immediately know how to respond – I gently place my hand over hers as her painful narrative continues. Louise is not only living in a shelter after a recent assault by a partner, but she has also been attempting to obtain a consult for gender reassignment surgery for months without success. Her physical and emotional trauma are incomprehensible to me – when did this woman last feel safe, or feel seen?
As I enter the remaining admission orders, a nurse approaches. “Is her room assignment right?” I check the record of her hospital wing and bed assignment – the hospital’s policy does not permit co-ed rooms. Yet, given the “M” next to “sex” listed on her medical chart, the system had placed her with three male patients. The attending and senior are elsewhere; do I step in? Trusting I am not overreaching, I thank the nurse and with his help, modify the assignment. We poke our heads back into Louise’s room and notify her a female or private room will be ready shortly. For the first time since meeting, Louise smiles: a hesitant, delicate motion that transforms her face entirely.
While the IV antibiotics run, we secure an outpatient urology surgical consult next month and repeat STI labs given her concerns. Over the next couple days, Louise’s pyelonephritis improves and with it, her mood. At each encounter, my attending or I perform a brief physical exam – not so much to check for costovertebral angle tenderness but rather to tangibly remind her that our touch, at least, carries no conditionality.
On rounds one morning, I relay that her cultures grew a resistant strain of E. Coli, to which she unexpectedly starts laughing. Taking in our confusion, she explains that the bacterium’s name reminds her of her pastor’s vibrant exclamations in Swahili, whom she proceeds to imitate with dramatic gesticulation. It is such a shift from our previously subdued exchanges that, despite our best professional effort, no one maintains a straight face.
For a moment, we all revel in the brief moments of levity the hospital so rarely offers. “She seems much better,” my attending observes as we exit the room. Yet nothing about her physical appearance obviously changed – her illness, after all, was a symphony of microorganisms and immune responses beyond our visual scope.
I think again of the hijra woman I’d met in India, who despite her societal “fall from grace,” retained an elegant and resilient spirit, validated by other strong women like my grandmother and indeed a “goddess” in her own right. Perhaps Louise, too, had finally found the space and care she needed to recuperate – to recover her sense of self: a combination of faith, fashion, and obscure R&B music beyond even a medical student’s capacity for study.
It is a simple act our team performs before her discharge: retrieving a comb and some nail polish, which we leave with her nurse. We knew a friend from the shelter would pick her up and that Louise was self-conscious about her disheveled appearance. But seeing her afterward, “relentlessly red” nails and all, makes the gesture totally worthwhile.
The aura of hopelessness hasn’t dissipated entirely. But she sits straighter, her eyes meet mine, and she engages with our team by asking questions or soliciting advice. For however briefly she was in our care, she was seen. For a few fleeting moments, Louise had a safe haven which, through a series of small acts on our part, gave her the freedom to “long, as does every human being, to be at home wherever [she] found [her]self.” Maybe in a moment of need Louise might remember our short-lived connection and feel her inner goddess reveal herself, fiercely and unabashedly.
Pallavi Basu is a fourth year medical student at UC San Diego School of Medicine. Her essay “Portrait of a Woman” received an honorable mention in the 2019 Hope Babette Tang Humanism in Healthcare Essay Contest.