It was 4:15 p.m. when my nurse gave me a “heads up” about the next patient. With a weary expression, she showed me a note affixed to the chart. “Mother is in waiting room and wants the patient to be tested for STDs,” it read. I scanned the chart before I entered the room. I had never seen this girl as a patient and did not know her. She was seventeen and had a thirteen-month-old daughter. The chart also told me that she’d had a sexually transmitted disease in the past, was currently experiencing pelvic pain, had no medical care in the past six months, and had gone about three months without a period. I tried to focus. More than a little frustrated that this patient was scheduled so late in the day, I began speculating about a diagnosis before I even entered the room.
Her slight frame was hunched over as she sat on the exam table. She wore sweats and sneakers, and a subtle curve of abdomen peaked out between her shirt and pants. The distress in her eyes as she searched mine was a contradiction to her otherwise childlike face. Her vulnerability hit me like a wave. My pace slowed, and reflexively my voice became softer. I felt guilt at my earlier desire to dispense quickly with this encounter so that I could arrive on time for an evening class I was team-teaching. She was poor. She was frightened. She was barely out of childhood.
A physical exam, a urine pregnancy test, and genital cultures confirmed my initial hunch that she had a sexually transmitted disease and was pregnant. She wanted an abortion. A few moments of conversation with this woman-child confirmed her poverty, her fear, and her immaturity. I prepared to call my teaching colleague and inform her I’d be late for the evening class.
I heaved a sigh of relief and actually felt gratitude toward my young patient when she told me she had already warned her mother that she was probably pregnant. In fact, after she missed her first period, she mentioned to her mother that she felt pregnant. She told me that her mother had delayed a visit to a doctor because they had no insurance and little cash. Since the mother already knew, there would be one fewer difficult discussion to have today.
When I was a young clinician, before my own marriage and motherhood, and before I realized the depths of my own vulnerability, I would have been inclined to judge the young woman’s behavior against my own well-defined beliefs. I have always been a strong advocate of the intrinsic dignity and value of human life, not only with regard to the fetus, but also with respect to the seriously ill, the impaired, and the marginalized. In fact, one of the reasons I did not pursue gynecology as my specialty was that I refused to be trained to perform a surgical abortion, a procedure that residents in many such programs are expected to learn.
What I now felt, though, had nothing to do with my own views or judgments. I saw the shamed expression on my young patient’s face as she told me she first thought she was pregnant two months earlier and had experienced bad abdominal pain on and off ever since. She was about to apologize for waiting so long to seek care when I interrupted her. “It’s good that you are here now,” I said. “We will figure this out together.”
“I don’t want it—the pregnancy,” she said.
I almost answered, “It’s not just a pregnancy, it’s your child,” but I said nothing.
I did gently probe for more background information, to determine both her physical safety and her risk factors for other problems. She told me that she was unable to use hormonal contraceptives, but assured me that she and her partner, another teen, used condoms. She had no idea why the condom had failed in this instance. I did not stop to consider whether or not she was telling the truth—at that point, the question seemed irrelevant.
She gave me permission to proceed with the exam, and I asked her additional questions as I noted a subtle convexity of her abdomen. I estimated, and later confirmed with blood work and an ultrasound, that she was at about thirteen weeks pregnant.
When I asked her how many sexual partners she’d had, she prefaced her answer with, “Not that many,” but told me she’d had three. I was glad I was behind a drape getting her Pap smear and cultures when she said this. Her naiveté about her unhealthy behavior startled me, and I feared that my facial expression would have betrayed my reaction. During the exam, we discussed prevention of STDs, and safe and risky sexual and social behaviors. I gently asked whether she had considered having the baby and allowing the child to be adopted. With the most emotion she had shown in the entire encounter, she told me that she would never have another child because of the bad experience she had had while in labor. I told her it did not have to be that way.
I habitually ask my adolescent patients what they hope to be as adults, and it seemed natural to ask her too. She told me she wanted to be a nurse. I felt a kind of relief that she had set her sights high. I prayed that her own experience would make her tender toward her future patients. I also prayed that, despite my fatigue, I would manage to be kind to her, to be her advocate. I recalled the times I’d made choices that caused me and others to suffer. Most often I’d made them when I felt a certain poverty of spirit or had forgotten my dignity. I wondered if this girl, in her impoverishment and her youth, had ever known her dignity and her destiny as one loved by God. If not, how could she begin to appreciate the life hidden and growing within her?
I completed the pelvic exam and helped the young woman out of the stirrups and into a sitting position. She then asked me to invite her mother in to discuss the plan. Dutifully, I escorted my patient’s mother and little daughter into the exam room. The walk down the hall seemed to take an eternity. Once in the room, the patient’s daughter climbed into her arms. The little girl’s braided hair fell about her face as she fumbled with her mother’s breast. Patiently, the young woman repositioned the child and directed her own gaze toward her mother. Tears welled up in the older woman’s eyes as her daughter said she wanted a termination. “She can’t handle another child,” the patient’s mother said. “We can’t handle another child.” I sensed in her a conflict between her personal grief and a visceral instinct to protect her daughter. In the end, both of them seemed resolute about the decision.
I treated the sexually transmitted disease and made a referral to an ob-gyn group rather than to an abortion clinic. I knew the group could provide obstetrical care as well as an abortion. What the patient and that provider eventually decided to do would be beyond my control. But if I delayed the referral or refused to make it, I feared the young woman would pursue a medically dangerous procedure or ultimately seek a late-term abortion. I wrestled with my conscience about not counseling her more strongly against an abortion, but on that particular day I was not able to make a further argument. I sensed in her vulnerability and weary desperation a depth of suffering that made my arguments seem pale.
I ended our encounter by telling the young woman that I hoped she would eventually come to know that she was loved, and that she would come to experience that knowledge in her life. I recalled a talk I had once heard by Cynthia Bourgereau, an Episcopal priest and contemplative, about how Christ harrowed hell by simply sitting there in love. I thought about the Gospels and the woman at the well, the demoniac possessed by Legion, the paralytic who was able to walk when Jesus had forgiven his sins, and the many lepers Jesus had healed and restored to their place in society. I thought that such love was probably the only thing that would save my patient, her children, and myself.
