August 7–14, 1997

cover story

When the Kids Aren’t All Right

By Daisy Fried

To protect privacy, most patients’ names and some details have been altered.

“You like cars?”

Liana R. Clark, M.D. — hair twisted in incipient dreadlocks, raspberry-colored fingernail polish, gold on her toenails, gold studs in her earlobes plus a sparkly one nesting up high under the rim of one ear — leans forward toward Tanya*, 14, and dangles a jangly key ring.

Tanya is here about an odd breast discharge, but she’s also getting Clark’s overall mental-physical teen health assessment, and has just confessed to skipping breakfast and lunch most days.

“OK, say I make you 16 right now,” Clark says. “Take my keys. Which is the car key?”

Tanya picks the big one with the black cover.

“What kind of car is it?”

“BMW,” Tanya says.

“OK, so I give you the keys to my baby,” Clark says, looking Tanya in the eye. “She’s beautiful, she’s black, her name is Nightshade, Shady for short. But I give you Shady with no gas in her. You aren’t going anywhere. You’re gonna sit there listening to my car radio, not experiencing the ultimate driving machine.”

Tanya gets it now. Smiles a shy, sheepish smile. And gets a lecture about what happens to your stomach, your brain, when you don’t eat. She nods at Clark’s suggestion that she drink at least one glass of juice and a piece of toast to get her through till lunch.

“Your body is not made to go over seven hours without eating,” Clark says. “You choose. If you don’t eat properly, it’s not my responsibility, and it’s not your parents’. We’re not gonna treat you like you’re 5. That’s why I work with teens. I don’t want to deal with 5-year-old little ratheads who you have to sit on just to examine. I’ll take my car keys back now, thank you.”

—-

Colleen, 14, has a red dot on the white of her eye. Medically insignificant. Most docs would say ‘don’t worry’ and send her on her way. But Ken Ginsburg, M.D. — denim shirt, khakis, tie,gelled curly black hair, dark brown eyes behind wire-rimmed glasses — has a question.

“How did you get this?”

“I got in a fight yesterday.”

“What about?”

“This girl was messin’ with me. She said my mother is a whore.”

“What happens now?”

“I’m gonna kill her. Today. I have a knife.”

Ginsburg avoids the typical adult response: lecturing, wringing hands, pleading: Don’t you understand?!! You’ll ruin your whole life! You’ll get hurt! You’ll be paralyzed. Too abstract. Instead he asks her to take out a comb she has in her pocket and pretend to stab him with it. She thrusts. He takes it out of her hand, pretends to stab her in the back.

“So, maybe you’ll never walk again,” he tells her. “You could end up in diapers, you could end up on a breathing machine. Did you ever think of that?”

“No.”

“OK, do it again.”

This time, he takes the comb and stabs her through the heart.

“OK, what do you call that?”

“Dead,” Colleen says. “But I’m gonna kill her.”

“What if she has a knife or a gun herself?”

Colleen thinks.

“So what do you want to do?” Ginsburg asks.

“Kill her. That’s why I’m going back to school today.”

“How will you feel if you kill her?”

“Good!”

“How long will you feel good?”

“All day!”

“How are you going to feel after that?”

The girl figures she’ll get probation, no big deal.

“Uh-uh,” says Ginsburg. “You’re talking first-degree murder. You’re talking premeditated. You’ll go to jail. You won’t finish your education. You won’t have kids. By the time you get out you’ll be too old to have kids. Your mother will be sad. Now. Suppose you don’t fight her today. How will you feel?”

“Bad.”

“How long?”

“All day.”

Bam, she gets it. Decides not to fight.

“The truth,” says Ginsburg, who’s also drawn her a decision tree with options and outcomes, “is she wouldn’t have come in if she weren’t looking for a loving, responsible adult to stop her.”

—-

Liana R. Clark, 34, and Ken Ginsburg, 35, are adolescent medicine doctors at Children’s Hospital of Philadelphia. They work in the clinic on the fourth floor of CHOP’s Wood Center overseeing residents and patients. Three days a week they operate Teen Health Associates (THA), a private practice within CHOP.

CHOP has long treated adolescents, providing them with routine health care for everything from acne to anorexia to gynecological problems. But recently, pediatricians have begun to realize that teens, especially in big, troubled cities like Philadelphia, need more than physical medicine — and that their health is linked to how they feel about themselves and about life. They need help navigating the adolescent minefield of drugs, violence and sex, skills to know how to make decisions: how to deal with life in all its increasing complexity. So a new specialty bridging the gap between pediatrics and adult medicine was created.

CHOP M.D.Gail Slap, director of CHOP’s teen health program, Ginsburg and Clark’s boss and a pioneer in adolescent medicine, says the adolescent medicine concept is to “provide what everyone does best with, especially teens: one-stop shopping for health care. We give them as much care as possible on one visit. If we can, we want to help the teens navigate the healthcare system with grace and ease and autonomy so they don’t feel overwhelmed.”

The adolescent medicine movement began about 20 years ago, says Don Schwarz, acting chief of general pediatrics and director of CHOP’s adolescent clinic. CHOP was one of a number of hospitals across the country that started to push the concept that teens need their own providers. But it wasn’t till 1994 that adolescent medicine became a certifiable subspecialty.

“It takes a while for anything to develop that far,” Schwarz says. “You have to get the whole field of pediatrics and internal medicine to acknowledge that it’s as distinct and different as, say, neurology and cardiology.”

To train for the field, a doctor must be a pediatrician, internist or family practitioner who does a special fellowship in adolescent medicine. Clark did hers at Children’s National Medical Center in D.C. Ginsburg did his at CHOP.

In 1994, Clark and Ginsburg were among the first to take the certification exam that Slap helped write. Now, besides seeing patients, both lecture extensively, do research, write articles and book chapters, and teach Penn med students to do what they do. Clark sits on the 8th District AIDS task force. Ginsburg is national medical consultant for Job Corps. Ginsburg consults on educational videos with titles like “Peer Pressure” and “Teen Sexuality.” Clark writes a health advice column for Hype Hair, a magazine for black teenage girls.

“They’re both incredibly dedicated, wonderful doctors,” says Schwarz.

The adolescent clinic at Children’s Hospital is teeming with teens and their parents. In a cramped conference room around the corner, Ginsburg is giving five med students and residents a quick teen health intro before they’ll fan out to six examining rooms to work with the kids.

“There are two numbers you must remember,” Ginsburg tells the students. “You must burn them into your soul, and think of them every time you see a patient. First, 80 percent of teen deaths are preventable. What do you think is the leading cause?”

“Accidents?””Violence?” his listeners guess.

“Violence is second — though in Philadelphia it’s first: it’s number one for oppressed people. Does that make you want to vomit?”

First nationwide is automobile accidents, usually caused by drinking or drugs. Then violence. Third, suicide.

“The second statistic you need to know is that 50 percent of kids who kill themselves saw a healthcare provider in the month before their suicide. Twenty-five percent, within a week. Which means, either, as a group, we’re driving kids to suicide, or else kids are seeking help and not getting it.”

Teens, he says, don’t come to a doctor and say,”Hello, I’m thinking of killing myself. They come with headaches, stomach pain.”

Ginsburg did a study of how many doctors did a psychosocial screenwhen teens came to the ER with that kind of vague complaint: 3.9 percent.

“You have to put teens’ complaints into context. If a teen presents with chest pain there’s a far greater chance that he’s suicidal than that he’s got cardiomyopathy.”

“We do regular doctor stuff. But beyond that there are three things we do. We assess kids before the onset of crisis. We talk about or do things that might change their behavior. And, as long as schools suck, as long as parents don’t know how to communicate with kids, as long as there’s economic injustice and poverty, we’re not going to change kids’ lives. That’s why we do political advocacy.”

“Is this not way too late?” asks a student.

“A fabulous question,” says Ginsburg. “Ideally you start much younger. But I will not buy into the bull that there’s not enough money, therefore you have to choose between children and teens. There is enough money. I refuse to give up on teens.”

“OK, we don’t know each other too well, but well, let’s just go around and say when the first time we’ve had sex was,” says Ginsburg. “Just tell me, you know, how old you were, was it with a man or a woman, did you enjoy yourself. Manny, you go first.”

The young male doctor perched on the filing cabinet gulps, hugs himself. “That’s kind of personal!”

“Exactly,” says Ginsburg. “It is not only personal, it’s offensive. Ask a kid that, the appropriate response is for them to lie to you, tell you what you want to hear. You must set the stage. First, I say to a kid, with the parent in the room, that I need to be a different kind of doctor than they expect. Yeah, I’ll do checkups, give shots, fill out forms. But I’ve got to do more if I’m going to save lives. I say to the kid, ‘You and I both know what kills kids. If you were a doctor, what would you talk about with kids? What do kids die of?'”

“Then you listen to what the kid says, because you learn a lot about their world view from their answers.Then I say, ‘I’ve got some rules to make it so we can talk and be safe. First up, you gotta know I’m not here to judge. Second, what we talk about will be kept private. I won’t laugh at you with other people, I won’t even tell your mom without your permission. But the best work I can do is help you talk to your parents.’“

“OK, what about mom? This part is hardest for me — goes back to when I was a neurotic little Jewish boy — getting mom to say, ‘Thank you for asking me to leave the room.'”

“Suppose mom says no, which almost never happens. I do what my mommy said to do when I’m about to have a conflict. I compliment: ‘I can’t tell you how pleased I am that you’re talking about these things at home.’ What is she going to say, ‘No, we don’t have discussions, I don’t believe in communication’? And then I say, OK, he’s 16, he needs to be able to talk to other people. It’s part of growing up. If they still absolutely refuse, then what?”

“Suspect abuse?” asks a student.

Ginsburg nods.

“By the way, Liana does it a little differently. She finds that if she goes through all that, she ends up in long discussions with the parent. Whether it’s because she’s African American, or because she’s a female, and people are less likely to challenge a male, I don’t know.”

—-

Shelita’s pretty, skinny, 15. She hunches in a THA examining room, feet together, toes in, knees out, hugging herself. Clark knows why she’s been referred here, but wants Shelita to tell her herself.

She talks to Shelita and her mother together, asking about Shelita’s medical history. Shelita’s mother supplied it before the interview, but Clark wants Shelita to learn to describe herself and what’s going on with her body.

Next, Clark tells them she will talk to Shelita alone.

“I want the family to communicate with each other. But sometimes kids think their parents will fly off the handle, so they don’t talk about what’s on their minds at all. Now, whatever you say, I never will say, ‘Oh my god, how could you!’ This is confidential, except for three situations where I will break confidence. Do you know what they are?”

“If I’m doing drugs?” Shelita guesses.

“Actually, no, not unless you are doing enough to hurt yourself immediately,” says Clark. “They are: if you’re going to kill yourself, if you are going to kill somebody else, and if you are being abused. Anything else is private. Any questions about that, sweetheart?”

“Mm-mm.”

“Mom?”

“Mm-mm.”

Exit mom. Clark asks Shelita about school, home life. Shelita’s angry at her father’s treatment of her mother. Clark hands her tissues when she starts to cry, tells her how, when she was a kid, angry at her mother, she wrote a note.

“If you start with ‘I’ instead of ‘you,’ no one can argue with you because you’re talking about your own feelings.”

Shelita tells Clark she doesn’t do drugs, drink, smoke or carry a weapon, that she feels pretty good about herself, has a boyfriend.

“Now back in my day a million years ago with the dinosaurs,” says Clark, “we talked about how far you get with a boy. Have you ever heard of the bases. Mm-hmmm. And do you know what they are? First base is kissing. Second is above-the-waist touching. Third is below-the-waist touching. Home is having sex.”

Pause.

“Could you tell me which base you and your boyfriend have gone to?”

Pause.

“Well, I guess I just skipped the bases,” Shelita says, all in a rush.

Clark nods.

“What you experienced is so common,” she says. “So many girls go from a kiss or two, then in, with nothing in between. A lot of teens think there’s no difference between sexuality and intercourse. Sexuality happened for me in fifth grade. I wanted a boy. I didn’t know what I’d do with him if I got him, but… it’s perfectly normal. How you choose to act, though, can mean the difference between having or not having a problem or a disease.”

Shelita’s all ears.

“When I was a teenager, me and my boyfriend would have all kinds of fun, but the thing is it never went too far. When I finally lost my virginity, I remember thinking, is this it? I mean, I liked all the other stuff so much, it was much more fun than somebody going…”

And Clark hits one hand against the other over and over in a steady dull thwack.

Shelita giggles, nods in recognition.

—-

“You have to look at what you hope to accomplish,” Clark says later. “I would love it if these children were not having sex till they could handle it, but you have to work where they are. If you try to curtail them, and give them ‘shoulds,’ you’re going to make them defensive and then you can’t reach them at all. You can’t start going, ‘You’re too young, it’s wrong.’ I do not condone their having sex; I try to give them permission to not have sex. One way to do that is to show them there are things they can do other than intercourse. They know so little. They say, ‘You mean I’m supposed to feel something? I’m supposed to enjoy it?'”

“There are great pediatricians, don’t get me wrong. But a lot of them don’t ask the right questions. Or they don’t have the right approach. I had a kid here with genital herpes. Her doctor went off on her: ‘You have genital herpes! I’m going to tell your mother.’ Now that is against the law. With kids 14 and up you can’t tell without the kid’s agreement. Then he told her, ‘We have to tell your boyfriend.’ She didn’t have one. He went off on that, too. She was devastated.”

“I’m an Internet geek, I debate this online. One guy said I should tell them not to have sex. I said, ‘If I tell them that, if they have a problem, how am I going to tell them to come to me with it?’ Another one said, ‘You have to talk to them about God.’ Come on! You don’t go to a doctor for religion!”

Back in the examining room:

“Can you say no?” Clark asks Shelita. “Go ahead, let me hear you.”

“Noooo,” Shelita giggles.

“Say it like you mean it,” Clark says.

“No!” says Shelita. Better.

“If you mean no, say no,” says Clark. “If you mean maybe, say maybe. If you mean yes, say yes. I tell my boys if a girl says no, no matter how she says it, it means no. And I tell them if the girl then says she didn’t mean that, he should tell her, ‘Say what you mean and mean what you say.'”

—-

“I’m working on a new concept,” Clark says. “There’s a continuum with sexual assault. There’s harassment, there’s rape, and in between there’s what I call ‘sexual martyring.’ Girls’ and boys’ socialization is different. Many teens aren’t comfortable saying no. And so they give consent by not saying no, even if they don’t say yes. Teens — and not just teens — get to a certain point in petting and think, ‘If I stop he’s going to think I’m a tease.’ There’s so much unpleasantness in dealing with ‘no’ that it’s easier to have sex. That’s not rape. But it is a bad — or at least a not-good — sexual experience: sexual martyring. You can’t look at it as the male doing something wrong. She hasn’t indicated she didn’t want to. But we as women have to be able to say no and feel comfortable about it.”

To get teens to understand the concept, Clark says, “OK, you’re with your boyfriend, you like him, he likes you, he comes up to you and says, ‘Sweetheart, let me scratch your head.’ And you say, ‘Well that’s kind of weird, but what the hell.’ So he’s scratching your head, scratching your head, and he’s in the throes of rapture. And to you maybe it feels good, but it’s nothing to write home about. You’re not getting the same pleasure as he is.”

—-

“There’s a tremendous amount of societal pressure on boys to have sex,” says Ginsburg, in his office under a wall of art-photo postcards of kids and parents. “They need to know it’s OK not to. But there must be an acceptable alternative. We lost Joycelyn Elders because this country wasn’t ready for that. But she got a standing ovation when she spoke to the American Academy of Pediatrics. I had a kid who said he was going to drop out of school because he was getting erections all the time, so much he couldn’t go to class. I thought I was being a cool doc. I told him how to manage his erections: wear his shirt out, think of dinosaurs dying in the sun. But then he walked out of school. He came back the next week. He said, ‘Don’t worry about it, I’m back, my dad told me what to do.'”

Father told son all he needed was to have sex.

“And that is why Joycelyn Elders is right,” Ginsburg says. “See, when people of our generation tell kids to be abstinent — which I am strongly in favor of — we think we’re just telling them not to have intercourse. They think it means no touching. No holding hands. No kissing. We had bases, right? We had all these messages of sexuality without sex: Marcia Brady, what a sex goddess — but she never slept with anyone. Happy Days. What was that show about? Making out! Now what you see is, boom, into bed, all or nothing. I want to get kids to say no to sex, yes to sexuality. That’s the difference between America and Europe. Europe does much better at that, and they have much better numbersfor teen pregnancy and STDs.”

Ginsburg told the kid there was an acceptable alternative.

“I don’t ‘teach’ masturbation. I just tell them it’s normal and healthy. You wouldn’t believe how many kids think masturbation’s a sin but having sex is not. Or birth control is a sin but pregnancy’s OK. Or that sex is a sin but birth control is a bigger sin.”

—-

Clark gives Shelita information about condoms and other birth control. She also gets her first ‘female exam.’ First Clark shows her a speculum, tells her what they’re for, and shows her a drawing of the female genitals.

“Take a mirror and look sometime,” Clark says. “No. Don’t say ‘nasty.’ It’s your body. It’s natural.”

Shelita’s nervous, but it’s hard to stay that way when Clark is singing “Speed Racer” and “Wadaleeacha” —

Wadaleeacha, wadaleeacha, doodlydo, doodlydo, it’s a simple little song, there isn’t much to it, all ya gotta do is doodlydo it, I like the rest but the part I like best goes doodly, doodlydo —

and telling her exactly what she’s doing, why, and how it’s going to feel as she goes along.

Clark encourages Shelita when it’s all over to tell her mother what they talked about.

“A lot of girls say they can’t tell, she might get mad. But I think she’d want to know. I have a little rathead cat and this morning he bit my hand and ran away for no good reason. I love him, same as always. It’s the same for parents. It might feel good to get it off your chest.”

Shelita says OK to telling mom about the pelvic exam but for the time being nothing more. And laughs as she takes a temporary tattoo of a hissing snake from Clark’s collection on her way out.

—-

Clark, single, of Mt. Laurel, NJ, comes from a family of doctors: mother, father, godfather, aunts.

“I was a 5-year-old feminist. Everybody kept telling me my mother couldn’t be a doctor, she had to be a nurse. I was like, ‘No way! She’s a doctor!'”

In high school she wanted to teach autistic kids. In college — Yale — she wanted to be a psychiatrist. At Howard University Medical School, she thought she was heading for a career in ob-gyn. Then, during her ob-gyn rotation, “I realized I was more interested in the baby than the placenta. I would be over at the incubator with the baby, and they’d be like, “Uh, Liana, could you come deliver this placenta?””

So she did her residency in pediatrics, where she gravitated toward teens. “Teen medicine indulges my interest in gynecology and makes me less of a frustrated shrink,” she says.

She did her residency at Children’s Hospital of Los Angeles, where she had trouble. Howard, she says, was strong in other areas of medicine but had a weak pediatrics program.

“I got a reputation for being slow and disorganized,” Clark says. “I thought, ‘I don’t need to work here, my people in South Central would be happy to have me.’ Even when I got my act together people still assumed I wasn’t very good.”

One very frustrated day, she saw a patient she had just seen a few weeks before. The girl had run away from home and had been living on the street, hanging with a gang. She’d been gang-raped by a rival gang. Clark had treated her gonorrhea and tried to persuade her to go home. The day she reappeared at the hospital, hanging around till she got a chance to talk to Clark, she told the doctor, ‘After I talked to you, I went home.’

“You could have knocked me down,” says Clark. “I took it as a sign — I do believe in signs — that I should keep doing what I was doing.”

Her fellowship in D.C. gave her a fresh start. Then she came to CHOP.

“I use my own life a lot,” she says. “I have no problem telling anything to anybody. I try to make it relevant, let them know I’ve been there. I had a screwed-up adolescence. And I’ve had some wild days, been there, done that, and that does help.”

—-

Ginsburg, married, with twin toddler girls, of Mount Airy, grew up in Haverford, always knew he’d be a pediatrician.

“But I was committed to social justice work. When I was 18 I worked on a Siouxreservation in South Dakota, and then many summers for the next 10 years. That’s an education in inequity, poverty, injustice. So I was on a med school track [Penn, Albert Einstein], but I also wanted to be an activist.”

He worked for New York’s Covenant House, staffing at the clinic by day, riding the van at night, “crawling through subway stations, under Port Authority, handing out sandwiches and hot cocoa, and hoping you’d get people to talk to you. It became clear to me that working with teens combined social work, teaching and medicine. One thing I was sure of was that I didn’t want to be an academic. But then [CHOP’s] Gail Slap up and gave me my life-defining speech. She said, ‘I’ve been watching you for three years. Did you ever think of teaching 100 people to do what you do one-tenth as well as you do it?”

—-

At THA, Clark and Ginsburg schedule an hour for each new patient, a half hour for return visits. Both oversee residents in the clinic, coming in after them if a teen’s having a difficult problem. THA takes only teens with personal insurance: not the way that Clark and Ginsburg like it, but what’s required by America’s insurance setup.

“We also take HMO referrals, but getting the family practitioner to make the referral is the hard part,” Clark says. “They say, ‘What can you do that I can’t do?’ I hate it. Teens say, ‘Can you be my doctor?’ and I have to say no. But it’s this or nothing at all.”

Many come to see the pair over and over, grow attached.

Calvin, a 16-year-old with bad family and self-esteem problems, refused to see a counselor, but said he’d talk to Ginsburg.

“I just went in for a checkup,”says Calvin.”Another doctor asked me to rate myself from 0 to 10. I said I don’t like myself much. She went out and got Dr. Ginsburg. He came in and talked to me. He asked me how come I felt that way. He said he never met nobody like me, like how I put my feelings in art and poems, instead of going out and messing things up. He helped me out a lot even just two times. He’s giving me spirit. I don’t have to hate myself, like I have good qualities, I’m special. Two times aren’t going to help everything but I’m going to keep going. When I first went in, he was straight up with me. He don’t cut corners. It’s just man to man. I know how to read people. He’s real. Two times I went he said he sees the good person in me, like I have a special place with him.”

Jacqualine Wilson’s father kicked her out of the house when she turned 18. She moved in with her brother, but had no insurance. It had been a long time since she’d had a checkup. A friend told her about Liana Clark.

“My family doctor was old as dirt,” Wilson says. “He didn’t ask about my personal problems, like girl stuff, like ‘Are you OK?’ And my friend told me [Clark] was really personal. I saved up for my initial visit. I got a checkup but she also asked a lot of questions. Like if I wanted to know about drugs or alcohol. I started to really trust her toward the end of the visit. She asked me if I had sex. I do. She asked if I used condoms, I said sometimes. She said, I’m not going to preach to you or tell you what to do, but I am gonna tell you what you can get into. And she’ll joke with you. She doesn’t tell you stuff like she’s preaching. I went to Catholic school, enough said there. She’s helped me through a lot of stuff.”

“Liana’s like a mother figure. I think she takes that position with some of my friends. Like I had a friend who was promiscuous and after she went to see Liana she didn’t do that anymore. I had another friend who decided to lose weight after she saw Dr. Clark. But the thing is she doesn’t push you into anything. She’s a really good role model. And she’ll tell you the honest truth.”

—-

Ginsburg’s been getting a lot of referrals lately for kids with drug problems. “The first thing you have to do is figure out why they’re using. Suburban kids use a lot more drugs than city kids, but they tend to be experimenters — you worry a little but not as much. Urban kids tend to be self-medicators. What I’m really worried about right now is marijuana. The drug effect of weed is, immediately, to relax you and make you not care. The long-term effect is an inability to care. And you find a lot of kids who come from the hopelessness and devastation of urban poverty self-medicating away pain. Crack begot violence, and people got upset, as they should. When you smoke weed you’re not hurting others, so no one cares if you hurt yourself.”

Ginsburg would love for kids to be able to tell their friends they’re spiritually, morally and politically opposed to drug use. But he knows that’s a pipe dream. So he’s come up with a crafty alternative.

“What I do is I allow the kid to blame the parent. The parent’s in on it. So next time his friends light up, the kid will say something like, ‘Man, my mother’s such a bitch, she smells my shirt and checks my eyes when I go home, and she said I come home stoned again she’s going to send me to my aunt in Carolina or to DHS or whatever.’ It’s a ruse. But it works great.”

—-

Ginsburg sees more boys, Clark, more girls: at THA, at least, kids are asked to choose; most pick their own gender. There’s a lot more mixing upstairs at the clinic.

Do race and gender issues ever get in the way of communication? Sometimes boys have a problem.

“You get a lot of ‘she just a ho, she just a bitch,'” Clark says. “I say, ‘How would you feel if someone called your sister that?’ Sometimes they’re so hardass, you can’t reach them. They’re like, ‘You a educated ho, you still just a ho.'”

“As an African-American success, I feel a debt to ‘my people.’ But with anorexics, I’m faced with such a schism. People think, oh, anorexic, white; sex, black. That’s not necessarily true. But the issues and problems that come with it — sometimes I feel like this is not a real problem. Of course it is, but sometimes it seems self-created. I never take it out on the child, of course. I realize that the same feelings that lead one kid to sex, another to use drugs, leads a third to stop eating.”

Ginsburg authored a study of why teens do or don’t choose to seek medical care. Race of the provider was neither the first nor the last reason.

Some teens said they thought white doctors tend to give more attention to white patients. One said, “I had a doctor, he couldn’t even talk to me. When he checked me and stuff, he was rough. This white lady was saying [he] was great, but he was treating me all bad.”

Some students said they had waited while white patients who’d arrived at the clinic later were seen first, but “were unfamiliar with the concept of triage and attributed waiting time to race or socioeconomics. When told patients seen quickly often have the most urgent problems, virtually all accepted this as an explanation,” Ginsburg wrote.

But, “almost every student agreed that they prefer to receive care from a clinic with racially diverse staff.”

Students made suggestions.

“Check that the clinic [has]… black and white and all different kind of doctors instead of just one race. See if they’re talking, then you know that… they all get along.”

Clark and Ginsburg also don’t assume kids are heterosexual.

James, 15, was so depressed that Ginsburg had a suicide contract with him: James was to call him, beep him, any time of the day or night, if he felt like killing himself.

One day he came in. He was waking up at 4 every morning.

“My mom wanted me to get some sleep medication from you,” he told Ginsburg.

Since there’s no illness in the world that wakes you at precisely the same too-early time every morning, Ginsburg did his psychosocial screen, asking open-ended questions about sex.

“Are you seeing anyone? What are they like?”

James — like many gay teens — answered in gender-neutral terms.

Ginsburg’s goal was not to out him. But the morning insomnia alarmed him.

Ginsburg told him, “Adolescence is such a crazy, confusing time. You’re supposed to want to have sex with everything that moves, and yet maybe you don’t want to. Sometimes you do want to. Sometimes with the opposite sex, sometimes with your own sex. Wow. Adolescence is so hard.”

Boom. Silence.

“I’m confused,” James blurted. “I wake up at 4 every morning trying to figure out how I’m going to kill myself before they find out.”

After that, Ginsburg and James were able to talk about James’ being gay. Turns out, James went home that night and came out to his family.

“I wouldn’t have recommended it,” says Ginsburg. “Turns out, his mom was a dream. He’s much better now.”

“You’re a powerful role model if you look like a kid or come from their background. It would be nice if I could be gay or a black female, or Latino when I need to be, but I’m not. The thing is, many kids want the doctor from across the town. They don’t want someone who knows their mother. And, I really believe that love supersedes what you look like.”

“In urban areas of concentrated poverty, kids are used to racist condescension from majority culture. If you have love toward them, if you are not fearful, I think it melts them. And I think the combination of me and Liana is a powerful message. She’s black, I’m white, I’m a guy, she’s a woman, I’m short, she’s medium-sized. They see us laughing, teasing, that we’re friends.”

—-

It’s by no means all success.

“There are some kids who are so heavy into drug culture you can’t reach them,” says Clark. “There are so many boys and young men who have lost any sense of morality. I think the general reason is no hope. There’s a light in kids’ eyes you look for that’s just not there. All you can do is try.”

Sometimes it’s terribly hard.

“I had a kid who at 13 had run away from home 20 times, had sex with everything that moved, took drugs, carried a gun. I told her about Tia,” Clark says. “Tia was a child in Washington who at 13 was diagnosed with HIV. She was another wild child: crack habit at 12, sex with everything, had been sexually abused by her mother. I told this girl how Tia and I bonded, how when I gave Tia that test result, I promised that no matter what happened she could call me. And she would disappear, and then when she came back she always did contact me, even after the time I had to have her arrested. Little by little, she moved away from that life. And I told this girl, ‘I can’t say I can change your life, I can’t say live with me in New Jersey. But if you get tired of living your life as if you do not care if you live or die, if you decide there’s hope left, well here’s my number.’ I left and the resident went in. When he came out he said, ‘Suddenly she decided she wants to go on the pill!'”

“Of course, I get a lot of converts in the office. Two days later my influence is gone. I can’t compete with the boyfriend who gives ‘unconditional love’ in return for no condom. There are kids whose lives are fuckedand there’s not a damn thing you can do about it.”

There was Lisa, 19, who came for care to Philly’s Covenant House, where Clark moonlighted. Clark treated her for chlamydia in June. In September, Lisa was back with the same complaint.

“Did you use condoms?” Clark asked.

“Well, no,” Lisa said.

“Well, why not?”

“Because I’m not with that guy anymore, this is a new guy.”

Clark walked out, paced up and down the hall. Then she told house staff not to run in if they heard screaming, and went back in.

“Look! Are you trying to die? Because if so, go find your coffin right now and do not waste my time! Did I not sit here and explain this to you? Didn’t I?”

“That poor child was like a deer in the headlights,” Clark says. “But I kept going:”

“I’m angry. I’m appalled. I don’t know what I need to do. What am I doing wrong? I need to know, because I don’t know how to fix this.”

At that point, Clark remembers, shestarted to sniffle.

“It’s not you, it’s not you,” the girl told her softly.

“But that’s when I knew I had to stop being a martyr,” says Clark. “Because if you’re a martyr you’re dead, and your patients go to somebody else. So I went to the Bahamas for four days.”

And Ginsburg: “I have to protect myself. That’s not profound. That’s reality. You have to get in touch with the rescue fantasy we all have in us. Sometimes you do rescue people. Mostly you don’t make the biggest difference. Some people may be saints. Not me. I find rejuvenation in my family and friends and also some of the students, who are a constant reminder that there is idealism in the world. And I get to show them medicine as it’s supposed to be.”