ID: 17 year old Hispanic female who attempted suicide with Tylenol, now medically cleared and admitted for psychiatric evaluation

Dear John,

I have wanted to write a letter to you, an 18 year old man I have never really met, since I had the privilege of meeting Diana, your ex-girlfriend, during her admission to the Child and Adolescent Psychiatric Services program.

My intern Will and I found Diana settling into her newly assigned room. She was wearing a faded navy sweater two sizes too large for her frame. We introduced ourselves and asked if she would accompany us into a nearby room so that we could talk comfortably. As we walked in the hallway, she tied her freshly washed hair into a bun and pulled up her enormous hood. No longer could I see her deep brown eyes that were hazy with unfallen tears.

In the interview room we oriented ourselves in a small triangle: Diana and me on a couch together, Will in a chair across from us. His voice was gentle and questioning was focused, “Diana, do you know why you are here?” She withdrew her hands into the giant cuffs of her sleeves and brought her knees to her chest, hugging herself. No one said a word for 10.. 15.. 20 seconds. She brought her right hand to her face, covering her mouth with a giant sleeve. 30.. 45… She sat still. A minute passed — that trick we were taught, to be comfortable with silence, didn’t seem to be working. It was Will who eventually broke, “Diana?” Muffled and cracking but without hesitation, “I took the pills because I couldn’t take it anymore.” “What was it that you couldn’t take?” he followed up. Slowly but a little louder,

“He hit me again.”

I could see the navy blue sleeve that was covering her mouth grow darker with tears, mucus, and saliva.

This was my introduction to you, John. I know it is an unfair and biased way of meeting you, but this was it.

Will asked what happened. Diana answered in an even tone.

“I had just gone to lunch with a friend so I didn’t respond to his text right away… So when he dropped me off, ’cause he drives me home after school… He was upset ’cause it took a long time ‘til I texted him. Just before he pulled in front of my house, he hit me on the leg. Punched I guess. And when I got home I just went into a daze and went to the bathroom then my room. I texted him that it was over, I opened the bottle, and I swallowed however many pills there were. And that was it. My mom found me and I guess you guys know the rest.”

And she was right, we did know the rest of the medical course. The arrival at the emergency department by ambulance, the trends in her liver function enzymes and blood clotting factors, closely monitored to evaluate for signs of acute liver failure. But that’s all we knew. Her trauma, your abuse; we were ignorant, and she the only expert in her experiences. So Will pressed her for more information. He conducted the formal intake interview, running through the necessary check-off list of SIGECAPS, family situation, access to weapons, etc. She responded with yes, no, I don’t know, or other similarly short answers. He then asked, “Do you feel hopeless?”

Diana sat back in the couch and pulled her hood off her head. She dropped her knees and lowered her hand. It looked like she suddenly grew before my eyes, spine lengthening two or so inches — now maybe even fitting that gigantic sweater. She wasn’t hiding anymore. She was not shrinking herself now. Something in her was alerted in that question.

“I don’t actually want to die. I don’t know if I wanted to die then. No, I don’t think so… Nothing was even different about that day. But uh yeah, I have hope. The only reason I told anyone what happened in the first place is I realized that if I don’t, he’ll just do it to another girl.”

John, Diana’s reason for maintaining hope was the possibility of ending your cycle of gender-based violence. Here we were, trying to unpack our patient’s traumatic experiences of intimate partner violence, to which one in ten U.S. high school students are subjected [1]. And Diana’s source of hope was not for herself but for another girl; Diana was protecting a sisterhood whose members were unknown but connected to her.

Will wrapped up the interview efficiently, assessing quickly that her suicidality had a specific trigger; there are increased depressive symptoms and suicide attempts among women who experience intimate partner violence [2]. He thus became eager to schedule a family meeting in which strategies of preventing a future suicide attempt could be discussed. It felt somewhat rushed, but what in medicine these days isn’t? Will turned to me and asked, “Nicole, do you have any other questions?” Any other questions. As if I could think of just one i he forgot to dot or t he forgot to cross.

“I have a few. Diana, is it okay if I stay behind and chat with you for a bit while Will meets with our supervising doctor?” She said, “Sure” and I felt grateful she was willing to humor me.

I turned our conversation around and we talked for half an hour about where we were from, what we wanted to do when we grew up, what it is like to be older sisters. We laughed at the way we each liked each others’ hair but not our own, and how the things we cared about as freshmen in high school seem so silly now. And when it felt like we could no longer ignore it, I turned to her and said that she is a fierce young woman, that this abuse was not her fault, and that her internal strength is obvious to me, someone who had just met her.

She said, “I know it is not my fault,” as she lifted her sweatshirt and pushed up her basketball shorts to reveal thighs covered in various hues of pink, red, purple, and blue. I remembered that you hit her again, that this incident was only unique in what happened afterwards to bring her into the hospital, not in the physicality of it.

“I know it can’t be. But I am ashamed. I feel ashamed I let this happen to me and that now my mom knows and how much she has cried. I hate to see her cry and I just don’t want her to cry anymore.”

I can’t even begin to imagine the pain a mother must feel to know that her daughter has been hurt, despite all motherly attempts to shield her. But again, I was humbled by Diana’s foremost concern for someone else. Her shame was rooted in the pain she believed she was causing her mother. In reality, John, you were the one hurting Diana’s mother.

She had an uneventful, which is to say good, remainder of her hospital course. I would check in with Diana daily and watch her self-confidence grow. She looked forward to family meetings during which time she’d hold her mother’s hand as a Spanish translator updated her on the status of the police report, restraining order, and insurance coverage. With Latina women less likely to formally report intimate partner violence than white women [3] (though this could actually be mediated by women’s economics given minority women’s disproportionate poverty burden [4]), I felt all the more inspired by Diana’s decision to seek action. She was nervously excited about going back to school because she had missed so many classes, but was in communication with her teachers who seemed understanding. When it was time for discharge, we hugged and I said goodbye to one of my youngest teachers. I can’t believe how much Diana taught me about female resiliency.

And John, while I am very clearly an ally of Diana, I also consider myself your ally. This is why I have wanted to write you a letter for so long.

You grew up in a world that prioritizes mens’ desires over womens’ rights. Masculinity is revered and central to growing boys’ and mens’ identities. And this maleness is predicated upon obtaining all that is presumably yours, by any means possible. A woman’s disobedience is thus not only an affront to your control, which must then be reasserted when challenged, but also to the core of your identity. This is the gender power dynamic ingrained in our society. You internalized it. And then you externalized it. So now we have “met.”

John, I am angry because of your gender-based violence and society’s complicity and tacit approval. Despite this anger, like Diana I too have hope. I hope that you take responsibility and own the abuses you committed against Diana. I hope you are able to see that your expectations of a partner were gendered, and that you took inhumane steps to obtain that which you assumed was yours. And I also hope you see that you were wrong in part because society is wrong, and that you have the obligation and opportunity to change it. I hope you see this daunting task as a collective responsibility. Because in actuality it is our duty to upend and redefine masculinity, and I hope you join me.

In solidarity,

Nicole

[1] Gressard, Lindsay A., Monica H. Swahn, and Andra Teten Tharp. “A first look at gender inequality as a societal risk factor for dating violence.” American journal of preventive medicine 49.3 (2015): 448–457.
[2] Devries, Karen M., et al. “Intimate partner violence and incident depressive symptoms and suicide attempts: a systematic review of longitudinal studies.” PLoS Med 10.5 (2013): e1001439.
[3] Kaukinen, Catherine. “The help-seeking strategies of female violent-crime victims the direct and conditional effects of race and the victim-offender relationship.” Journal of interpersonal violence19.9 (2004): 967–990.
[4] Barrett, Betty Jo, and Melissa St Pierre. “Variations in women’s help seeking in response to intimate partner violence: Findings from a Canadian population-based study.” Violence against women17.1 (2011): 47–70.

Originally posted at femd.

Advertisements