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Medical Humanities

The Illness Script of Sexual Assault

Jack Penner

August 1, 2018



“Sometimes I just wish he had messed me up more . . . that something worse would have happened.”

Her eyes fixed on her white knuckles, her fingers contorting and wrapping themselves around one another, I wondered if they would forever be leached of color and a sense of calm.

“Maybe then I could have my body back, you know?”

I nodded, but I didn’t understand. I can’t. I won’t.

I’ll never know what it’s like to be kidnapped as an American woman in a foreign country. I’ll never know what it’s like to be tied up, raped, and threatened with murder. I’ll never know what it’s like to hold in my terrifying secret out of fear of losing my job, or to return home to a culture in which silence is a requisite to dodging guilt, isolation, and blame.

But she does, and she knows it all too well.

“You’re tough, Allie.” My compliment must have felt empty.

“Thanks.” She lifted her eyes, which hung with a weight of frustration and fatigue that I have seen only in those who have lived a lifetime of suffering in a matter of years. The homeless, the addicted, the suicidal.

Allie was 26.

“That’s the problem, though. Isn’t it?” she asked.

Yes. That was exactly the problem.

For the 15 months since her attack, Allie had white knuckled her way through the nightmares, the flashbacks, and the anxiety. They followed her like a haunted mirror that revealed a reflection she thought unworthy of love. With his beer-tinged breath, clammy hands, and cowardly threats, her attacker had left within her a ghost of rejection and disgust that awoke in every moment that called on the night’s sensory memories.

He had caught Allie on the street in an urban downtown as she tried to hail a cab. Living back in a major U.S. city, she re-lived the event every day. The crisp bite of moonlit air, the whizzing motors of a metropolitan street, the taxis, the sirens, and even the rhythmic “plock plock plock” of her high heels walking on concrete yanked her back to the moment her body became someone else’s.

Now, after hospitalization for PTSD and suicidal thoughts, she was asking for the help her grit talked her out of seeking in the weeks after the attack.

“If I had told someone, I would have had to come home and abandon my work. I would have felt like a cop out, a failure. I just… I figured I’d be fine.

“But, there was more to it. I really didn’t want to deal with everything that comes with this. The judgment, the second guessing, the questions.

“‘Why do you think this happened? . . . How did you end up in that situation, Allison? . . .What do you wish you had done differently?’

“Well sir, I could have traded my genitals for a Y chromosome the moment I got boobs.”

At a time when she wanted the emotional support and mental health resources to reclaim a piece of herself stuck in some man’s shabby apartment, our healthcare system said, “No.” According to the insurance company, Allie’s case did not warrant coverage for the intensive mental health services her psychiatrist– a specialist with sexual assault survivors– recommended.

As we bartered with the insurance agent, explaining the nature of Allie’s situation and the extent of her attack, I could hear his robotic adherence to the algorithm in front of him– his roadmap to denial.

“If the event had been severe enough to induce this degree of psychiatric dysfunction, why did it take her so long to seek services and support? Something isn’t adding up and it doesn’t meet our criteria for coverage. I’m sorry.”

In other words, her lived experience didn’t fit the textbook or his preconceptions, and thus, he couldn’t understand why she hadn’t sought help earlier. Of course he couldn’t. Like me, he will never know Allie’s hell, but he had made decisions about how long she stays in it. In an attempt to avoid the baggage of sexual assault reporting, Allie tried to process the trauma alone. According to the insurance agent, the average person doesn’t wait 15 months after a rape to seek help. Her strength and grit had become her biggest problem.

Subjugated to competing demands and someone else’s interpretation of her reality, Allie found herself in familiar territory for sexual assault survivors. Encouraged to be strong but punished with vitriolic labels when they are. Push through the suffocating vulnerability of sharing their story, and they hear they are mistaken, hyperbolic, histrionic. Like her body, Allie’s mind, rattling with anxiety, fear, and flashbacks, had started to slip from her grasp. I wondered if she could have avoided ending up here. Then again, it seemed that wasn’t her choice to make.


In medicine, we often talk about illness scripts -– the common narrative that most diseases follow. Years of patient cases tell us a virus lasts 5-10 days, pneumonia can linger for six weeks, and unless his blood tests positive for troponin, that man isn’t having a heart attack, no matter how much his chest hurts. This type of hard data works well for clinical diseases rooted in reproducible evidence.


However, the human mind, full of memories that coalesce and disperse through time, offers nuance that transcends any illness script we could write. Stories like Allie’s are atypical, messy, and painful, but also human, and most of all, true. When we try to collect emotional experiences across the arc of a life and average them into one, generalizable trajectory, we serve an average that catches the reality of only a few people, if any.

There’s no illness script for trauma and no blood test to diagnose whether or not Allie was living through a nightmare her attacker yanked her into. The effects of abuse shape-shift around the objective data to which healthcare clings. We are left with only stories. All of them deserve to be heard. Every survivor deserves support.

Allie and I were close in age, enjoyed the same restaurants and coffee shops, and exchanged podcast suggestions and book recommendations. We had both played the same sport in college and, when the conversation would lighten, we shared stories about growing up on the West Coast and making the move out East. She was also an artist, and about to begin a graduate degree in design. Our individual lives up to that point had overlapped in more areas than they diverged. Without coverage for her mental health care, the likelihood of that shared similarity ever returning seemed low. Not because we were suddenly different, but because, in the aftermath of her sexual assault, a list of men she had never met had exerted unchecked power over intimate aspects of Allie’s life– her body, her mental health, and her sense of self.

Allie’s attacker had silenced her, violated her, and stolen her sense of safety. Decisions about her care found their way into the hands of a man who not only rejected her story, but also lacked the experiential fluency to translate her words into emotional understanding. She was now living out a trajectory written by people she never wanted to let into her life, and she had no say in when this would all finally end.

Luckily for Allie, she ended up receiving the intensive therapy she deserved. As I watched my supervising physician approach Allie with empathy, compassion, patience, and trust, she found the space to recreate her sense of self and cut her ties to the guilt, shame, and self-judgment that entangled her entire being. One afternoon, I walked out of clinic and saw her sitting on a bench, drawing flowers on the back of her wrist.

“I used to give myself fake tattoos,” she told me. “I’m starting to draw again.” For the first time since I’d known her, the color had returned to her knuckles and her hands sat with a calm stillness.


Allie had begun to reclaim pieces of herself that never should have left, after walking through a hell she never should have seen. But, this is neither hopeful nor inspiring. Allie’s care cost thousands of dollars. It was her only option to avoid becoming one of the 13% of rape victims who attempt suicide1. She already fell in the category of the 33% who contemplate it1. Coming from a wealthy family, Allie had the financial resources to shoulder the cost. Most don’t. Her recovery was a victory against very long-odds.


As long as we rely on illness scripts to decide who deserves insurance-covered care in the wake of sexual assault, Allie’s improvement will remain a rare occurrence and we will continue to tell survivors that wealth is a prerequisite to reclaiming control of their identities. Healthcare can free sexual assault survivors from at least some of the weight of trauma. How many people like Allie never get the chance to feel light again?


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  1. Kilpatrick DG, Edmunds CN, Seymour A. Rape in America: A Report to the Nation. National Victim Center and Medical University of South Carolina. 1992;1(1):1–18.