Perspective
Shining Light in Dark Places
By Therese Zink, M.D., M.P.H.
Officer Jerry hands me the digital camera. “Please take pictures of his bottom. He was paddled with a skillet.”
I grimace and examine the camera. “Pretty straightforward,” I say. Officer Jerry nods; he’d called me earlier that morning to tell me there was a child abuse case that needed documentation. I asked him to come just before lunch so we’d have enough time. I never want to rush a child through this type of examination.
I glance at the chart, a 7-year-old boy; the last name is familiar. The fact that I know the family gives me pause. I’ve cared for Nicholas’ stepmom, collected Pap smears, treated anxiety, and prescribed birth control. I’ve asked her about domestic violence several times, which she always denies. I’ve never met Nicholas, but his father has brought some of the younger children in for immunizations. In this small rural community, I’ve seen Dad pushing the youngest in a stroller down Main Street. The preschooler pedaled a tricycle along side, and the kindergartner rode a two-wheeler with training wheels. Now this.
The nurse rooms Nicholas in the minor procedure room so we won’t be crowded and so I have good light. The social worker sits on a chair next to the sandy-haired boy who sits tailor-fashion on the gurney, his bottom cushioned by a pillow. He colors in a Mickey Mouse coloring book.
“Hello, Nicholas,” I say. “I’m Dr. Zink. I hear that you have some owies that I need to check.”
Nicholas looks up and gives me a shy smile.
“Tell me what happened last night,” I say, pulling up a stool in front of him.
“It’s okay,” the social worker says, putting a hand on his shoulder. “She’s here to help you.”
Nicholas puts down his crayon and stares at me with a matter-of-fact expression. “I was bad. My Dad spanked me.”
“Tell me about the spanking,” I say and mentally shield myself from what I am about to hear.
“On my bottom. It hurts.” Nicholas tells me that his Dad used a skillet. I don’t ask what he did. It really doesn’t matter. I focus on Nicholas and search for the words to ask the questions I need to ask in a way that will not frighten him or make him a victim again.
“My mouth is sore, too.”
“Tell me about that.”
“I said something bad when I got home from school. Dad put the soap in my mouth.”
“How long did you have the soap in your mouth?” I ask. I can see small tears at the corners of his lips.
“I was allowed to take it out for dinner,” he says. “We had pizza. It burned.”
He wrinkles his brow in the same way characters in the comics do when they’re thinking. “Then I had to put it in again until I went to bed.”
“What time was that?” I ask.
“About 7:30.”
I do the math. Home from school, about three, out for pizza, maybe an hour if we’re lucky, then back in until bedtime, three or four hours.
“How did you sleep last night?” I ask, steadying my voice.
Nicholas shrugs, and I learn that he slept in the stairwell between the first floor and basement as part of his punishment. The social worker’s eyes grow wide as Nicholas describes camping under the stairs with his pillow and blanket. Thankfully, the door between the stairwell and the kitchen was left open. I wonder about his stepmom, did she intervene? And the other children, they are all younger, where were they?
The horror sits lodged in the back of my throat; I want to cough it up and out. Horror at what people do to people they love. And yet, although, I don’t have kids, I’ve met the child abuser in myself while caring for a niece who would not stop whining for her parents. Nothing I did would reassure her, and the whine grated like nails on a chalkboard. I know every parent, every adult for that matter, has the capacity to hurt the child who won’t stop nagging or crying.
The social worker explains that Nicholas has been living with his dad and stepmom and their three children for the last few months. Before that he stayed with his mom in a nearby town and attended a different school. Now I understand why I’ve not met Nicholas before; but it isn’t clear why he moved away from his mother to live with his father and stepmother.
I take a deep breath and begin the most delicate part of the interview: “Did anyone touch your private parts?” I ask, pointing to my own genital area.
Nicholas shakes his head.
The social worker leans forward, places a hand on Nicholas’ shoe and adds, “It’s important to tell the doctor, even if someone told you not to tell. The doctor can help you.”
“No one hurt me there,” Nicholas says, keeping his gaze down.
“Good. I would want to know if they did,” I say. I ask the social worker if she has any other questions. She asks if he’s been punished like this before, and Nicholas affirms that he’s been spanked in the past.
It is time for the exam, and I explain that I need to see where he is hurt. I tell him that we need to take pictures of his owies because his dad should not have paddled him so hard. I ask him to move to the side of the cart, and he winces as he scoots forward. First, I examine his mouth. His cheeks and tongue are red, and the top layer of skin inside his mouth next to the corners of his lips is abraded. “Does your mouth hurt?” I ask, feeling the lump in my throat again.
“Sort of.” He tells me he was able to eat lunch, but the juice burned.
I take photos of his mouth asking him to lift his upper and lower lips for me. He giggles as I demonstrate. Handing the camera to the nurse, I methodically look at his ears and neck. There is comfort in the routine, searching for bruises or burns. I examine his arms and torso—every inch of skin; lifting the gown from the sections I need to see and then covering them. The yellow-green bruises I find on his shins are older, probably from play. His feet dangle; his scuffed gym shoes chop the air.
On his backside, the purple starts at the base of his spine. I position him on his side and have him curl up in a fetal position, draping the sheet to cover him. I swallow a scream as I lift the sheet and take in the bruise that is Nicholas’ bottom, a watercolor in blue and purple.
Anger! It boils through my blood and the camera feels slippery in my sweaty hands. Anger, no, rage, at how Nicholas’ father has punished him. Spanking is controversial, but this is over the top.
I frame Nicholas’ bottom in the viewer on the back of the camera and push the button. Flash. The camera illuminates the bruise. Was his father disciplined like this as a child and now only does what he knows? Will his father get the help he needs to learn to parent differently? Will there be a positive outcome from my efforts? The camera recalibrates, and I change the angle and push the button again. I document the injuries, the dark side of human life, what one person can do to another, what an adult has done to a child.
At least one out of 10 children in the United States is a victim of abuse— physical or sexual—or neglect, when basic needs such as housing, food, clothing, education, and access to medical care are not provided. Abuse is more common among the poor, but no socioeconomic stratum is immune. As a physician, I am mandated to report the abuse and neglect of children and seniors. My job is to document what I see and hear, then place it in the hands of the courts. Often, I don’t know the outcome. Sometimes, because social service workers are so overburdened, my reports fall on deaf ears. Will these efforts today make a difference?
Two more photos and then we are done, I tell myself. Flash. Flash. “Nicholas, you can get dressed,” I say, relieved to be done. I high-five him, thank him for his help, and promise him stickers.
In the hall, I flip through the photos with Officer Jerry, again horrified at what I’ve just witnessed, but I maintain my professional demeanor. “These are great,” he says and thanks me.
Great, great photos of abuse, but I know what he means. He will pick up the paperwork at 3 p.m. The social worker will take Nicholas to a foster home, and I suggest that she instruct them to bring him back if they have any concerns.
The adrenaline has petered out, and I push myself to complete the documentation in Nicholas’ chart before I take my lunch break. Methodically, I type the note into the computer, print it out, and draw the bruises on a body map—a black-and-white outline of a child’s face and body, front and back, on an 8 x 11 piece of white paper. All the papers are sealed in a manila envelope for Officer Jerry.
Usually, I run during the noon hour, and today I am especially eager to do so. The back door of the clinic slams behind me and my shoes slap the asphalt. I pound out the previous hour, sledgehammer to stake. I run past corn and soybean fields. Colossal tractors stir up dust clouds as some are harvested. Others are silent, expectant, the crops baking in the late autumn sun. With each breath, I expel the black-and-blue images. Sweat dampens my armpits and spine, the poison leaking out.
My morning with Nicholas ripples through the afternoon as I wearily minister to another dozen patients, each with an ache, fever, or worry. The memory of Nicholas’ blue-and-purple bottom haunts me, and I silently mutter prayers for him. As the last patient leaves the exam room, I hang my white coat and stethoscope on the hook behind my office door and head home. The rest of my chart notes can wait until morning.
At home, I yank off my clothes and step into the steamy shower. I rub the bar of soap on my arms, chest, and stomach. I scrub my skin with my loofah and reach behind my shoulder blades and back scouring with a wash cloth. When every inch of skin is clean, I wet my hair and lather until I have created an afro of suds. Bending forward at the waist I perform a yoga cleansing breath, pulling air into my abdomen and rolling those muscles up and down, up and down. I exhale with force. I repeat this five times. Dizzy, I anchor myself on the shower stall tile and rinse off, running my fingers through my hair and across my body. Skin stinging, I towel off as I watch the bubbles circle the drain and whisper a prayer for Nicholas and his family. I think how all have the capacity to be abusers and risk of being victims and pray that both receive what they need to heal.
I pull on my flannel nightgown and cinch the belt of my robe around my waist. Before making dinner, I plug in the tiny white Christmas lights that drape the windows in my living room. I leave them up all year to brighten the late fall and winter nights. Tonight, I am thankful for their luminescence.
Several weeks later, Nicholas’ foster-mother brings one of her other children to the clinic. I inquire about Nicholas. She tells me that initially he had some trouble getting to sleep at night, but now he’s adjusted and seems to enjoy the company of her other children. “He helps one of the younger ones color in our coloring books,” she says. I smile, remembering how fervently he’d colored here and wonder what shadow the abuse will cast on his life.
Shortly after, the nurse who assisted me with Nicholas hands me a newspaper and points to the article describing the conviction of Nicholas’ father. He will spend several months in jail. A few weeks later, I see Nicholas’ stepmother and ask her how she is doing at home alone with her three children, now a single parent.
“I’m getting used to being on my own,” she says. “There are advantages, you know.” She tells me that she continues to see her therapist.
Again, I ask if her husband, Nicholas’ father, ever hurt her.
“I wouldn’t let him hit me,” she says. “I’m bigger.”
I decide not to ask her what she had done during Nicholas’ punishment. But she agrees to sign a release so I can talk with her therapist. The therapist tells me that the stepmom was present during the abuse. “During the episode she froze,” the therapist tells me. “She relived what she witnessed as a child and was incapacitated.”
Even today as I write this, nausea rises. After 20 years in practice, I have not become accustomed to the dark side of life. Fortunately, it presents infrequently; but the horror is always as sharp and piercing as an ice pick. I’ve learned to “protect” myself, to be especially nice to myself that day. If I can only shine some light into the darkness, do my part to keep it from being repeated in the next generation. I inquire, make the report, and hope it will make a difference. I am less attached to the outcome, more tolerant of the overburdened social service system. Often, progress seems to be measured in teaspoons.
Nicholas’ father is now out of jail. I saw him pushing the stroller down Main Street with his kids the other day. It was a sunny spring day. The toddler was in the stroller, another child walked along side. The third child pedaled behind. I drove by, saw them, then looked in the other direction as I wondered how things were at home. MM
Therese Zink is a family physician in Zumbrota, Minnesota, and a professor in the department of family and community medicine at the University of Minnesota.