Preventing child sexual abuse

Content: nothing graphic. Discussion of adults not believing children.
I think this is a good thing for non-parents to read too, since neighbors, teachers, and family friends may be in a position to notice something is happening.

Edited to add: I later found the site “Mama Bear Effect” which I think is a good, evidence-based guide to practical actions to reduce risk.

A while ago a relative expressed worry about the possibility that her child might be sexually abused in the future. Other adults in the family assured her that children are very safe nowadays and that there was almost no risk.

As someone who works with sex offenders, and as the parent of a little girl, this question interests me a lot.

I think it’s important to know the actual risks, because in the past programs have been aimed at preventing risks that weren’t particularly likely: stranger rapes by “predators.” You don’t want to frighten people about events that are very unlikely, but you also don’t want to ignore more likely risks.

How common is it?

• It’s notoriously hard to collect good data on this, but a metastudy concluded that the sexual abuse prevalence rate for girls in the US is 10.7% to 17.4% and the rate for boys is 3.8% to 4.6%. This is for contact abuse only (abuse that involved touching, not something like an adult showing their genitals to a child).
• Sexual abuse rates seem to be declining, probably because of greater public awareness and less tolerance of abuse.

Characteristics of children at risk:

• Risk factors, in order of magnitude: being a girl, having low socioeconomic status, and not living with both biological parents (foster children are most at risk). There are racial differences but they all disappear when you control for class and family structure (source). Other risk factors include being socially isolated, not having someone to confide in, having a mother who is dead or mentally ill, and having parents with alcoholism (source).
• Boys are most at risk as very young children (peaking around age 4), and less at risk as they get older. Girls’ risk peaks once around 4 but rises to a higher peak around 14. (source)

Characteristics of perpetrators:

• Perpetrators are usually a family friend, neighbor, or babysitter. Family members are next most likely, with strangers being fairly unlikely (14%).
• Different sources estimate that 87% to 95% of perpetrators are male. (source, other source)
• About a quarter of the time, the perpetrator is under age 18. 14 again seems to be a particularly risky age. I’m not sure how much of this pattern is 14-year-olds assaulting other 14-year-olds (or how much the 14-year-olds would consider consensual, or how much a 14-year-old can consent).

(source)

How do you find out?

• Sexually abused children usually don’t tell anyone during childhood (source).
•  If children disclose abuse, they are most likely to tell their mothers and adolescents are most likely to tell a friend. Teachers are third most likely. (source) To me, this points to the importance of having a relationship where your children trust you. I’ve heard horror stories from clients about not being believed, or even being beaten, when they told their parents they were being molested. This made no sense to me until I reflected that the abuser was usually a respected person like the mother’s brother or the parish priest. I also think parents are sometimes so overwhelmed by horror at the thought of this happening to their child that they refuse to believe it.
• Rather than giving one complete disclosure, children often drop a hint, see what the reaction is, and then decide whether to drop more hints. To me, this again underscores the importance of paying attention to what children say and responding sensitively.
• It’s fairly common for children to recant or change stories after disclosing abuse, presumably because the memories are difficult to deal with or because it’s causing a stressful situation. (Imagine a child who discloses first to a sibling, then to her mother, then to the child protective worker, then to the police investigator, then a taped deposition for the court—she may recant just to make it all stop. Some families choose not to press charges for this reason.) Memory lapses are also a post-traumatic symptom, and it’s possible some children genuinely don’t remember. I have no idea how you tell the difference between the retraction of a false story and a true one, but it’s considered very unlikely that a child would make this up.
• Sexual drawings and age-inappropriate sexual behavior may be an indication that something has happened.

Protecting children:

These are my personal guesses, not proven strategies. Some other ideas here.

• Listen to children. Pay attention to their fears and concerns.
• Drop in unexpectedly when children are alone with an adult or an older child. Offenders are rarely caught in the act but are often caught pushing boundaries.
• Notice your child’s mood after they have been alone with an adult or older child.
• If your child seems uncomfortable around someone, err on the side of keeping them apart even if you haven’t gotten to the bottom of the situation.
• Make clear to children that they will not be blamed for disclosing and that sexual abuse is never children’s fault.
• Respond with support and love if they disclose something. Let the child know you appreciate their bravery in telling, and that it is now your job to handle the situation. More good tips here and here.
• If you hear a disclosure, you will probably experience shock, rage, and sadness. Try to stay calm around the child—let them see that you can handle hearing this. Find an adult you can vent to, so the child does not have to take care of your emotions.
• Respect children’s boundaries. Don’t make them hug or kiss people they don’t want to, even if grandma is expecting it. In a discussion on boundaries at a Quaker community where I lived, one woman recounted that when she asked a six-year-old girl in the community for a hug, the girl answered, “I only hug people in my family.” The woman held this up as healthy development to be celebrated. Teaching children phrases like this, or a simple “No, thanks,” teaches children that it’s fine to refuse unwanted attention.
• Unfortunately it’s unclear how well any of this works.

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Anger management curriculum for prisoners

When I first led an anger management group at the jail, most of the curricula I could find seemed pretty terrible: preachy and unrealistic. After leading the group several times now, this is what I’ve come up with. A few things are gleaned from the internet but much of it is my own. Feel free to use an alter any of the material that don’t have an author listed.

It’s an eight-week group meeting for one hour each week. Some of the classes don’t really last an hour, but people are fine with getting out early.

Session one: Intro
Group policies (attendance. responsibilities of facilitator and group members)
Discuss quote: “Usually when people are sad, they don’t do anything. They just cry over their condition. But when they get angry, they bring about a change.” – Malcolm X
(Because he was a leader of the Black Muslims, you might not want to quote Malcolm X if there’s heavy race-based conflict in your facility. As a white person, I chose to quote a black leader who was a former convict because I think it indicated that my allegiance wasn’t just to my own group of white prison staff, and I want to shake up expectations around the class.)
How can anger be used productively? List positive and negative applications of anger.
Discuss different ways of expressing anger (assertive, aggressive, passive aggressive, bottling up).
Homework: anger inventory

Session two: Neuroscience of anger
Explain that by looking at people’s brains with scans, scientists can tell that different parts of the brain are more active when people experience different emotions. Some of the more basic parts of our brain are good at protecting us, but don’t always know best. Anger can hijack the more advanced parts of our brain in charge of planning and reasoning.
“Flight or flight” handout – discuss positive and negative applications of this reaction (e.g. rescuing someone in danger or escaping danger vs. fighting someone over a minor problem)
“How anger works in the brain” handout
Discuss other factors that affect how the brain works (sleep deprivation, hunger/low blood sugar, caffeine, alcohol, drugs) and how they affect anger
Discuss how general stress level predisposes you to overreact
Homework: anger incident

Session three: Anger scale
Introduction to anger scale. Draw scale 0-10 on a poster. If someone is at 0 anger, how do they feel? At 3? At 5? At 7? At 10? What might they do at these different levels? Discuss difference between the anger you feel and the actions you take: someone at 8 might feel like throwing punches but doesn’t necessarily do so.
Checkin: what was the highest you got on the anger scale this week? How did you handle it?
Activity: pass out slips of paper, each with a scenario that might make you angry. Each person reads theirs (allow people to pass or hand these off to a neighbor in case they’re uncomfortable reading). Discuss each scenario: How mad would this make you? What’s your interpretation of the situation? What would you do?
Homework: anger incident with anger scale

Session four: Hidden and open emotions
Check-in with anger scale: Each person (including facilitator) says the highest number they reached on the anger scale during the past week. They can tell about the situation if they want.
Group activity: each group has a poster with a scale of “least OK to show in jail” to “most OK to show in jail.” They have post-it notes with emotions (happiness, sadness, hate, love, homesickness, fear, humor/fun, anger.) As a group they position the notes along the scale. Whole class discusses why they placed the notes where they did.
Discuss how everyone experiences the above emotions in jail, but some are more acceptable than others. Fear or sadness may get expressed as anger because that doesn’t make you as vulnerable to being taken advantage of.
Homework and List of emotions

Session five: Resentment and forgiveness
Check-in with anger scale
Difference between in-the-moment anger and ongoing resentment/grudges
Reading aloud: Nelson Mandela on forgiveness. I start by summarizing the background of South African apartheid (total inequality of the majority, more severe and long-lasting than American segregation, Mandela imprisoned for planning to overthrow the government.) This reading is unfailingly popular because the group members are impressed with the horrific details of Mandela’s 27-year imprisonment and the fact that he then went on to be the leader of a nation.
Discussion of what it takes to move on emotionally from the experience of being imprisoned.
Discussion of how to handle long-lasting anger (e.g. against family members who neglected or abused you in childhood – many inmates have had this experience). When do you find you’re able to move on and still interact with the person? When do you decide it doesn’t work to have this person in your life?
Homework: grudges

Session six: Apologies
Check-in with anger scale
Dicussion: how can you tell when someone’s apology is fake? What makes you feel an apology is sincere? Can give examples of politicians’ or other famous people’s “non-apology apologies”, ones that lay the blame on other people for being upset rather than taking responsibility for their own actions.
Read aloud/summarize: The fake apology
What makes an apology go well or badly in your experience? How do you make amends when you have hurt someone? How do you reconcile when both people have wronged each other?
Homework: read Anatomy of an apology

Session seven: Anger in relationships
Check-in with anger scale
Reading aloud: Fighting fair: Rules for couples
Discussing this reading easily takes most of the hour. Try to focus the discussion not just on what participants’ partners have done wrong (this is where the conversation naturally goes) but toward how to handle unfair actions a partner has taken, how to handle your own impulses toward unfair behavior. What constitutes abuse? When is it time to break up? To me this is the saddest session because it becomes clear how few of them have been in a reasonably healthy relationship or even see that as a possibility.
Homework: What advice would you give to a young person on how to handle disputes with their partner?

Session eight: Anger and children
Check-in with anger scale
Discussion: For those who are parents, how do you handle anger towards your children? Amazingly to me, someone often says that children are too young to know better and he couldn’t get mad at his child. (I suspect many of my group members who are fathers have not spent much time, if any, with their children due to incarceration and separation from the children’s mothers.) I give the example of a toddler sticking their finger in your eye. Even if they’re too young to know that it hurts you, it still hurts and you’re probably surprised and angry for a minute, and it might take some effort to respond appropriately to the child. I also ask if anyone present believes their parents never got angry at them. If all of our parents got angry at us when we were kids, we will probably get angry with our kids too.

How do they feel about physical punishment? What’s the difference between spanking and beating? (Expect this to bring up strong feelings for some people, as it would be very unlikely to have a group of prisoners in which no one was physically abused as a child.) If you choose to spank your child, how do you keep from going overboard? To me, the upshot is that the parent has to be in control of their own behavior. Don’t spank your child if you’re too angry—whatever discipline you give must be for the child’s well-being, not for venting your own frustration. Time-out is not just for children; you may need some time to cool down before you’re able to respond appropriately to whatever your child did.

Presentation of certificates
Discussion: suggestions for improvements to the class.
Thank class for participating actively in discussions.

Some other bits that get tossed in as appropriate:

A brief moment of CBT: It’s not just the situation itself that makes you mad, but your interpretation of it. If someone bumps into you and you think it was on purpose, you’re madder than if you think it was a mistake. At times we assume the worst and get angrier than is called for. How can we check our perceptions?

A frequent topic during check-ins is: why are some correctional officers such assholes? A good time to introduce the concept: “Hurt people hurt people.” (People who are hurt, hurt other people.) If someone comes in to their job and acts rude and difficult, it’s probably not because all is going well in their life. We can’t know what’s going on, but we can guess they’re not feeling good inside. It doesn’t excuse their behavior, but it may help us understand better.

Self-disclosure on the part of the facilitator is really tricky. In the weekly check-ins, I don’t want to be the only one who doesn’t share. But I also can’t talk about a lot of possible causes of anger—disagreement with coworkers or my husband are off the table, for example, because they’ll start picking apart the mental health team or my marriage and none of that ultimately helps them trust that I am a person competent to help them. Also, a lot of the causes of frustration in my life are ones they would love to have. I’m grumpy because the baby was teething all night? They haven’t seen their children in weeks, months, or years. Traffic was bad? They dream about being free to drive again. Etc. I’ve found the safest strategy is to just give a number and be vague about the actual cause (which they are free to do also) or to have a gripe about my in-laws. Everyone is pretty much on the same page there.

Expect that some topics will bring up strong emotions. Anything about children is emotional for parents separated from their children. Topics about relationships are difficult for people who are worried about their partners leaving them while they’re locked up. In the exercise with slips of paper with anger-provoking scenarios, I recently had someone react very strongly to the slip he drew, which I thought of as something pretty minor. It turned out to have been a situation that kicked off a melee in which he was stabbed.

Address other topics as needed. The week that two buildings of people were crammed into one building while renovations were done, their anger about that was our main topic. The week of the Baltimore riots, we talked about how a situation that suddenly erupts may be a product of a long-simmering anger, and what makes a public expression of anger productive or unproductive.

In the trenches

Nobody in social work school teaches you how to do short-term work in chaotic environments.

They teach you how to terminate a relationship with clients at the end of the 8 sessions you planned or when they’re “graduating” from therapy, but not when any session could be your last, when she could be shipped off to state prison any week now, when his brother could bail him out any day now.

They teach you how to structure a 50-minute hour but not a stolen 12 minutes when nobody is using the caseworker’s office. In the lectures on confidentiality they don’t tell you how to speak in code so your client will know you’re asking if his antipsychotic medication is working but his cellmate won’t understand.

There are books and seminars on treating PTSD symptoms, first establishing a therapeutic relationship, working on coping and safety skills, and only then processing traumatic memories. But they don’t tell you how to handle someone whose PTSD is eating them alive and who will only be at your facility for two more weeks, when you only have time for two sessions because there are 73 other people on your caseload.

There are whole theories about whether you offer a crying client a tissue from the box on your desk or wait to see if they take one. There is no theory about the most sanitary way to carry tissues in your clipboard to the corner of the TV room where you will end up meeting, or whether to help your weeping client wipe their face when their hands are shackled behind their back.

And that’s okay. I understand they can’t cover every possibility and some things you just have to learn on the fly. But there’s an implication from all the classes and books that after you do your time in the trenches you will eventually be an outpatient psychotherapist, with an office and a desk with tissues on it and one of those white noise machines outside the door. And I dream about it—what art to have on the walls, how to arrange the chairs. I dream of working in a place where I can eat lunch with metal cutlery, where I can wear scarves because the dress code doesn’t forbid things the clients can use to choke you. I dream of the therapy I could do with a 50-minute hour every week for years.

But there are a lot of clients who will never make it to that Zenlike office. They’re not in outpatient therapy because they’re busy getting high, or they’re hospitalized, or they’re incarcerated, or they have no insurance, or they have no bus fare, or they didn’t know therapy was a thing.

And if hospitals and jails are places people only work while they’re fresh out of school and waiting to get to private practice, the neediest clients will get the least experienced clinicians every time. That’s not fair to them.

When I have a client who really needs good ongoing therapy, I wish I could be sure they get it. I explain how it’s supposed to work, and when they leave I make sure they have appointments. But I know they probably won’t make it there, because their lives are too chaotic. And they will eventually wind up meeting with someone in the corner of an emergency department or a shelter or a psych ward or a holding cell. I hope the staff there are really good at what they do.

Caring

I was struck by this card from PostSecret.

Sometimes I hear people say they aren’t inclined to talk to a therapist about their problems, because they’d rather talk to someone who “actually cares about them.” Two points:

1) Talking to your friends is always going to be limited by things you are embarrassed to tell your friends.

2) You may have underestimated just how bleeding-heart some of us are.

Granted, this medical transcriptionist is a lot more bleeding-heart than average (and maybe more than the patients want). But there are a lot of us out there.

Recently one of my chronically suicidal clients asked if I get sad when clients die. I was surprised that he even asked, but I checked my assumption that he knew I cared about him. I told him that yes, I get very sad and would be particularly sad if something happened to him. I didn’t tell him that I dream about my clients, that I lie awake worrying about them, that I pray for them despite not believing in God.

It had been on my mind anyway, because one of my former clients had died that week and I had indeed been very sad about it. I heard it was a heroin overdose.

Of course, there are people in the field that don’t care. The client who just died once told me that she was worried about her boyfriend because he was doing way too much heroin and the EMTs were getting tired of reviving him. She said they had offered him a Do Not Resuscitate letter, apparently hoping that they could just let him die next time he overdosed.

If you get to the point where you’re tired of helping people, you need to get the hell out of health care.

So yes, it’s possible you’ll get a burnt-out therapist who isn’t really listening and doesn’t really care. But it’s also possible you’ll get someone who cares way more than you believed possible.

A few days before Mother’s Day, I was in the lobby of the building where I had just taken my daughter to the pediatrician. She wasn’t gaining weight properly, and I was panicking despite the doctor’s reassurances. I huddled on a bench with her, trying to control my tears before we went out to catch our bus home. Dozens of people walked past me.

One of them, a woman in scrubs, came back a few minutes later and handed me this.

She was right. They did.

Talk so people can understand you

Sitting in with other clinicians or the psychiatrists at work, I’m surprised at some of the phrasings they use. Please don’t ask someone about “suicidal ideation” — “thoughts about killing yourself” will make more sense. And no one (at least in our patient population) describes themselves as “irritable.” But “aggravation,” that resonates. “Do you get aggravated easily?” will bring a hearty “Yes!” from clients who scratched their heads when you asked about irritability.*

Because social work occupies a weird non-medical niche in a medical world and we have a chip on our shoulders about the fact that we do real clinical work, our notes have to be more formal than the doctors’ notes. Specifically, social workers tend to refer to themselves as “this writer”, which drives me bananas. As in, “This writer attempted to meet with client, who was unavailable due to being in the shower.” I’m not sure why an awkward writing style proves our professionalism.

I’m also disturbed by officialese on signs that people really need to understand. Take this one I saw recently:

“No questions asked but information may be given” — what does that mean? Who is giving information about whom? Presumably they mean “We will not ask you questions, but you can give us information if you want to.” But if I’m a nervous teenaged parent, that “information may be given” might scare me off.

I’d like all emergency signs to be written in simple English, without the passive voice, suitable for reading by people with limited literacy or English skills.

*Some questions are just hard to get across regardless of how you phrase them. The question about anhedonia — have you lost interest in things you used to enjoy? — usually prompts my clients at the jail to answer, “Yes, my freedom!” My favorite answer was a thoughtful, “I used to enjoy watching soccer, but since I moved to this country, I don’t enjoy it anymore. The soccer here is just terrible.”

Screening questions

Recently I overheard a man in a store complaining about the stupid questions they ask you at doctors’ offices.  “Do I feel safe in my home?  Are you kidding me?  I weigh 250 pounds. You think somebody’s beating me up at home?”

I understand his annoyance – I’m annoyed when I call the nurse hotline and have to go through questions about whether I’m having symptoms of stroke or heart attack.

But I wanted to ask him, “What would you like the weight limit to be for that question?  Would 225 pounds be small enough?  Should there be a height requirement, too?  How does that nurse know your partner isn’t 300 pounds?  Or maybe 95 pounds with a wicked right hook?”

At work I routinely meet with men who report that their female partners hit them.  They don’t bother calling the police, because guess who gets arrested on a domestic violence call? It’s not the one who weighs 95 pounds.

Likewise, most people laugh or get offended when I ask them if they hear or see things other people don’t.  “Look, I’m not crazy!” some of them say.  But they’ve never been there for the interviews where someone looks at the floor and says, “Actually…”

Some people seem to find the abuse questions pointless, but occasionally I get people who find them pointless in the opposite direction.  I once asked a young prostitute if she had ever been sexually abused.  She looked at me like I was stupid.  “Well, yeah.”

What needs to be done

I was struck by the descriptions of nursing in Louisa May Alcott’s Work: A Story of Experience  (not the greatest novel, but a fascinating take on women’s careers in 1860s Boston). The last of the professions our heroine turns her hand to is wartime nursing, just as the author did in the Civil War.

A senior nurse commends the heroine:

“You are a treasure, my dear, for you can turn your hand to any thing and do well whatever you undertake. So many come with plenty of good-will, but not a particle of practical ability, and are offended because I decline their help. The boys don’t want to be cried over, or have their brows ‘everlastingly swabbed,’ as old Watkins calls it: they want to be well fed and nursed, and cheered up with creature comforts. Your nice beef-tea and cheery ways are worth oceans of tears and cart-loads of tracts.”

. . . . Mrs. Sterling, Jr., certainly did look like an efficient nurse, who thought more of “the boys” than of herself; for one hand bore a pitcher of gruel, the other a bag of oranges, clean shirts hung over the right arm, a rubber cushion under the left, and every pocket in the big apron was full of bottles and bandages, papers and letters.

The 1860s were a pivotal time in the development of nursing – in England, Florence Nightingale was just founding the first secular nursing school. Clara Barton, “the angel of the battlefield”, was gaining the experience that she would use to professionalize American nursing. But at the time Alcott trained, nursing involved no formal education, no study of biology. Both nursing and medicine in general were at such a basic stage that nurses were basically trying to keep the patients from bleeding to death, and if possible to keep them comfortable and in good spirits.

Given how much actual medical care nurses are now responsible for, I’d much rather have a nurse who can put the right drug in the IV line than one with “cheery ways.” But some combination of both would be nice.

Currently, medical and social services are segmented enough that I’m a little envious of 19th-century nurses’ ability to actually do tasks that they saw needed doing. Help a client call his mother? No, that’s the caseworker’s job. Get a client in solitary confinement the Danielle Steel novel she’s asking for to pass the time? That’s the librarian’s job, except he never seems to make it up to the tenth floor. Helping a bulimic client brainstorm about how to drink more fluids – that would probably be the nutritionist’s job if he hadn’t been laid off.

At its best, I think social work includes things beyond talk therapy. Getting a cup of coffee for a woman who just arrived at the domestic violence shelter with two children and a trash bag of belongings. Spending a therapy session helping a client write a resume. Getting a pair of reading glasses for the hospital patient who lost hers. Getting a Spanish-language Koran for the prisoner who wants to read his holy book in his own language. No, it doesn’t take a master’s degree to do any of these things, and when they need to be done en masse it’s worth having someone whose job that is. But when random needs come up, sometimes it’s better to just get the job done.

Who does behavioral health care?

Warning: serious alphabet soup ahead.  A helpful guide.

People get confused about who does mental health care.  (Or, as insurance companies call it, behavioral health care, because that encompasses not only what’s wrong with your brain and your childhood, but also your drinking problem and your marriage.)  If you talk about a “therapist,” people think you mean anything from a 15-minute medication checkup to hours-long Freudian-style psychoanalysis.

The old stereotypes are that a psychiatrist sits behind the couch and says, “I see,” a nurse takes your temperature, and a social worker takes your children.  More modern people think that psychiatrists prescribe your medication, psychologists do psychotherapy, and social workers shuffle papers or work with the homeless or something.

I wanted to see how true any of this was, so I decided to start with a listing of who insurance companies list as behavioral healthcare providers.

Methods: I got the list of behavioral health providers within twenty miles of me (this encompasses the greater Boston area) from my insurance website (Anthem/Blue Cross). I drew a list of 100 practitioners.

Limitations: I started with the Zs and drew 60 names before realizing they skewed Jewish, which might affect career choice, so I switched to names starting with T, which seemed to be more ethnically mixed.  Also, Boston may be skewed in various ways because it has a lot hospitals and a high cost of living.  And maybe providers who take Blue Cross are skewed in some way.  Plus there are people practicing (not-yet-licensed folks under someone else’s supervision) who aren’t going to be listed officially.

Results:

social workers: 43
psychologists: 31
psychiatrists: 15
nurses: 5
licensed mental health counselors: 3
licensed marriage and family therapists: 2
licensed clinical mental health counselors: 1

Within some of these fields, there are multiple types of license. The psychologists were PhDs (doctors of philosophy, presumably in psychology),  PsyDs (doctors of psychiatry), and EDDs (doctors of education).  The nurses were RNs (registered nurses) and NPs (nurse practitioners).  Some of them can prescribe medication.  All the social workers were LICSWs (licensed independent clinical social workers).

Discussion:

This is a measure of providers, not visits.  A prescriber might see three or more patients in an hour for medication adjustment, while anyone doing psychotherapy is probably only seeing one client an hour.  (Rumor has it there are still a few psychiatrists doing 50-minute psychotherapy sessions, but I’ve never met anyone who’s actually met these people.)  So those 15 psychiatrists and 5 nurses might be seeing the same number of patients as the other 80% of non-prescribing practitioners.

While there certainly are social workers out there running domestic violence shelters, etc., it also seems that most psychotherapists are social workers.  (I’ve heard that psychologists do a fair bit of administering tests, which might pay better than therapy.)

This is the result I was hoping to find, but I promise I would have published even if it hadn’t been.

Thoughts on fatherhood

I was interested to see this take on whether men should be required to financially support their biological children, even though they don’t have the same choice women have about ending a pregnancy or placing a child for adoption.  Legally, their decision-making ends with insemination.

I worry that this policy creates bad outcomes not only for fathers, but for mothers and children.  I can’t find data, but folk wisdom among domestic violence workers is that domestic violence often increases during pregnancy.  I’ve worked with multiple women who say they lost pregnancies to partners’ violence.  One of them said that after her injuries, she can never bear another child.

I have no way of knowing what was going through those men’s minds, but I wonder if it had to do with 18 years of child support payments. I wonder if some legal way of shrugging off responsibility would have prevented them taking matters into their own hands.

On the non-violent side, I’ve seen a couple of fathers come in for refusing to pay child support.  Both of them said they had the money, but preferred to spend a month in jail.  One of them explained, “I know she’d just spend it on cigarettes.”  (For his own safety, it’s good he said that to me and not to any of my colleagues who are single mothers.)

I’ve also seen paternal behavior that was heartwarming rather than horrifying.  The two men who I’ve heard question the paternity of their children did not want this to change their relationship to the child.  One of them described his routine with his daughter: getting her ready in the morning, taking her to school.  “I’m not even on the birth certificate,” he said sadly.  “She might not even be mine.  But she’s still my daughter.”

Yes, it’s a small sample, and maybe a biased one.  Men who go into a murderous rage or daytime-television-style celebration upon learning their babies aren’t their babies are unlikely to talk to me about it.  But it still makes me question claims by people like Robin Hanson that paternity tests should be required.

Triage

I hear that in other countries, people acknowledge the existence of medical rationing.  In the US, we like to pretend it doesn’t exist.

A jail is a microcosm of this: there is only one source of medical care, and the limited number of hours must be divided somehow among all the possible recipients. With 1600 prisoners (many of them with mental illness) and less than one full-time psychiatrist, there are never enough appointments for all the people who want them.

Where I work, the mental health clinicians are the gatekeepers for those appointments.  When one of our clients is in crisis, the mental health clinicians can make an argument to the rest of the team on why this person should see the doctor sooner.  A debate follows about symptoms, history of hurting self and others, risk factors, and whether medication is even likely to help.

During those debates, part of me always wants to say, “Yes, get him the damn appointment! I can’t stand to go back and tell him he’s not getting a med change for another five weeks!”

The other part thinks, “Who will get bumped if I move him up? Is it Angie, whose nightmares are waking her up screaming?  Khalil, who says the voices are getting louder?  Ernesto, who’s having panic attacks every time he leaves his cell?  Can I make them wait another week?”

These are the things that are happening every time we distribute resources, but they’re usually not as visible.