VIEWS & REVIEWS

REVIEW

Written on the body

Doctors must pay serious attention to the ways in which biography and biology interact in order to make a difference in cases of child abuse, writes Iona Heath in a review of this book
Human beings do terrible things to one another, causing deep wounds that leave scars that may be anatomical but that can also be physiological, directly affecting the functioning of the body. The significance of these scars is only now beginning to be recognised by medical science, and this book has a major contribution to make to this process. Anna Luise Kirkengen is a Norwegian general practitioner and academic whom I have known and respected for several years. Her original research work has included in-depth interviews with survivors of sexual abuse, and she uses these often harrowing stories to underpin this important book. The first of these stories concerns a girl of 14 who developed sudden pain and numbness in the left side of her body. She was seen by a neurologist who could find no cause for her symptoms and who referred her to a child psychiatrist. Eventually the girl revealed that she had been raped by a loved and trusted uncle the year before, but at this time no one asked her about the detail of this awful experience. When, much later, she was given the opportunity to describe precisely what happened, she was able to describe how her uncle leant over her left side, intruding on her left field of vision, and that she tried to push him away with her left arm. This girls pain could not be explained in terms of biology but made absolute sense in the context of her particular biography. Kirkengen faces the legacies of human cruelty without flinching and carefully documents the ever increasing body of evidence that shows the extent to which the aftermath of stress and trauma is not only distress, misery, and suffering but also a physical alteration in the bodys structure and function. Those caring for patients with mental illness are repeatedly reminded not to forget the poor physical health of this particularly vulnerable group of patients, but Kirkengen argues persuasively for a much more fundamental integration of the whole medical endeavour. Biomedical science persists with the totally artefactual division that separates the body and the mind and the illnesses of the one from those of the other. All too often this consigns all the legacies of stress, violence, and abuse to psychiatry, which is viewed as a quite distinct and separate arenaone which, again all too often, is geographically separated from the other domains of healthcare. Perhaps only general practitioners try systematically to bridge this deep divide. Chronic adversity in its various forms, including relational or structural violence, economic hardship, loss of work, alcohol- or drug-addicted spouses, sexism or racism, or long-term care of severely diseased children, all leave their imprint in the functioning of the bodies they affect. Mothers caring for sick children have a higher risk of cardiovascular disease and lower telomerase activity and shorter telomeres than expected for their age. Sudden trauma or cumulative stress overwhelms the bodys capacity to adjust to changing circumstances, impairing immune metabolic function and eventually causing premature ageing and early death. Kirkengen combines her own direct experience of listening to profoundly traumatised patients and her extensive understanding of the relevant scientific literature and of the phenomenological philosophy of Maurice Merleau-Ponty to make an unanswerable case for a profound reorientation of medicine. She describes Merleau-Pontys insistence that human beings are in the world as bodies. This, she writes, means that human beings can know nothing, feel nothing, learn nothing, experience nothing without their bodies being part of the knowing, feeling, learning, and experiencing . . . Whether an experience is joyful, rewarding, conflicting, saddening, terrifying, or shamingjust to mention a few of a broad spectrum, and only as if all experiences were unambiguous, which they are not, as we all knowthe joy, the reward, the conflict, the sadness, the terror, and the shame fill the body. They are embodiedin their diversity and, very often, their ambiguity. The current blinkered state of medicine leaves much human suffering unattended and ignored; and only if we, as doctors, really begin to pay serious attention to the intricate ways in which biography and biology interact do we have any hope of responding in a manner that even begins to be appropriate, let alone adequate. Children who, more than anything, have learned that they are worthless and not appreciated turn into young people who know neither their right to be protected nor how to protect themselves. Doctors who try to treat the consequences of abuse without understanding or even acknowledging the cause have little hope of making any real difference. Kirkengen quotes Walter Benjamin: The diseased have a highly particular knowledge of the state of society. And she argues that human violence, exercised by those with more power against those with less, explains much health inequality and that asymmetries of sickness and premature death may be indicators of societal constellations characterized by asymmetries of power. I am pleased that Anna Luise asked me to review her book, because it obliged me to read a text that I might otherwise have put off. Her challenging analysis is richly rewarding and makes the contemporary obsession with lifestyle diseases seem even more superficial and makes the inherent victim blaming seem even more shocking. Iona Heath is a general practitioner, London iona.heath22@yahoo.co.uk
Cite this as: BMJ 2010;341:c6122

The Lived Experience of Violation: How Abused Children become Unhealthy Adults Anna Luise Kirkengen Zeta Books, 25, pp 335 ISBN 978-9731997469 An ebook is also available (see www.zetabooks.com) Rating:

****

Doctors who try to treat the consequences of abuse without understanding or even acknowledging the cause have little hope of making any real difference
BMJ | 13 NOVEMBER 2010 | VOLUME 341

See PERSONAL VIEW, p 1052, and MEDICAL CLASSIC, p 1055

1053