Perspective

Daughters’ Keeper — The Care and Treatment of Black Girls in America

List of authors.
  • Kevin M. Simon, M.D.

Article

I have avoided writing about my little girl for nearly 4 years, in part because I haven’t wanted to process my experience with her in real time. Everything is constantly changing, like the expressions that canter across her face yet disappear when my camera is ready. I am continually learning about being her dad. But having engaged with many girls of a similar hue who carry pain and burdens beyond their years, I know that each of them, too, is someone’s little girl. Their futures can be filled with opportunities for unencumbered discovery, growth, and learning, if they’re given space to be themselves. I write now to recognize their curiosity, freedom to be children, and experiences of maturation, hopeful that the same recognition will be afforded to my daughter.

Being a Black father raising a Black girl is exciting. Being a Black pediatric and adolescent psychiatrist and addiction medicine specialist caring for Black girls and women within various systems of care troubles me. Black girls in America receive conflicting messages about who they’re supposed to be: superheroes (#BlackGirlMagic) or, more commonly, supervillains (#AngryBlackWoman).

Although media, advocacy, and academic efforts have drawn attention to intolerable abuses of Black boys,1 we often fail to acknowledge the experiences of their female counterparts. Perhaps we’re too ashamed to examine a centuries-old reality: Black girls are harmed by the intersection of racism and sexism. These “isms” manifest in biases, stereotypes, and practices that render Black girls vulnerable to abuse, dehumanization, and death. Our silence about Black girls has clinical consequences throughout their life span.

When I interview Black girls and their parents, I hear common themes — experiences in which normal emotions are caricatured, classic symptoms overlooked, and their voices ignored.

Elementary school version: The parents of three Black girls sought consultation regarding a possible mood disorder in their 8-year-old middle daughter. During a pre-evaluation meeting, school officials told me they’d “successfully” placed her in time-out daily for weeks, for infractions ranging from not following directions to yelling at a classmate who sat in her seat. Three times, she was removed from school, taken to the emergency department of a large academic children’s hospital, and discharged home.

When I spoke with her parents, they described her as more rigid and sensitive than her sisters — characterizations in keeping with her diagnosis of autism spectrum disorder (ASD) level 1, without intellectual impairment. Nevertheless, she was affable when not being teased or annoying her siblings. I interviewed the family for more than an hour. When asked about school, the father said, “She’s not well understood,” and he questioned whether the school environment did more harm than good. The mother asked about bipolar spectrum disorder or seasonal affective disorder, noting the cyclical worsening of the girl’s mood in the fall. The girl was pleasant and keen to talk to my stuffed animal, asking it, “What’s your name?” She said she liked learning; having seen her report cards and academic test results, I agreed.

Assessment: An 8-year-old Black girl with ASD, exhibiting signs of ASD in school.

Plan: Acknowledge severe disparities within our mental health care system; many families have no way to fill the void when a patient doesn’t meet the clinical criteria for inpatient psychiatric care or when no inpatient bed can be found. Validate the father’s observation that his daughter is misunderstood at school. Share the evidence that a disproportionate number of girls of color are subject to disciplinary actions in elementary school.2 Inform the mother that the evaluation revealed no symptoms of pediatric bipolar or disruptive mood dysregulation disorder. Note that their daughter is affable and pleasant when not teasing her sisters. Encourage positive parenting strategies such as praising of positive behaviors. Coordinate a clinician–educator–parent team meeting to discuss developing the equivalent of a 504 plan (Section 504 of the Rehabilitation Act of 1973 prohibits discrimination against persons with disabilities, but private schools with no federal funding are exempt).

For Black girls, I am primed to think in hyperboles, but we must acknowledge that these girls are in fact just girls. No child is one-dimensionally “good” or “bad.”

Teenage years: While covering the adolescent inpatient psychiatric unit, I received a morning report that a “hot-tempered” 16-year-old Black girl admitted for suicidal ideation with plan and intent was causing the team problems. When I met her, this teenager with a child’s face and tight curls frizzy around the temples quickly informed me, “You got 3 minutes.” I recognized signs of emotional trauma, bilateral abrasions on her arms’ medial and lateral eminences — nonsuicidal self-injurious wounds, too numerous to count. Careful to respect her preferences, I asked, “Would you like to listen to music?” She obliged; I chose Beyoncé’s “Bigger”: “If you feel insignificant, you better think again…Life is your birthright, they hid that in the fine print / take the pen and rewrite it…Step in your essence and know that you’re excellent…You’re part of something way bigger…Bigger than the picture they framed us to be.”

Assessment: An appropriately guarded 14-year-old Black girl with a history of unspecified trauma- and stressor-related disorder and self-harm.

Plan: Remind the staff that she is 14, not 16. Black girls are regularly adultified owing to historical biases that strip these girls of childhood freedoms and dangerously blend girlhood and womanhood.3 Inquire more about the girl’s suicidal thoughts. Suicide rates among Black adolescents have been increasing dramatically for more than a decade, the sharpest rise occurring among Black girls.4 Enhance the use of psychosocial interventions by and for the patient; suggest that she listen to music or write a few sentences when her emotions rise (a technique drawn from cognitive behavioral therapy). For those who cut, having one less layer of skin than others means feeling all our world offers, beautiful and abject. That missing layer can be replaced with language and therapy if it’s done thoughtfully. The following day, the charge nurse tells me, “Your friend wants to be first to meet with you.”

Our culture teaches us to assume that Black girls can “handle it.” However, we frequently mistake their resilience for the absence of harm and miss opportunities to validate their experiences. Moreover, one can be resilient and nevertheless have post-traumatic stress disorder (PTSD).

Emerging adult: “I’m tired of hospitals.” Even through email, I felt the patient’s exasperation. A 23-year-old Black woman with PTSD, attention deficit–hyperactivity disorder (ADHD), and a history of cannabis and some opioid use presented to an emergency department reporting abdominal pain. Sent home, she felt dismissed. The pain did not relent, and she returned hours later. This time, she was reportedly told, “We’re not giving you pain pills. I’ve seen your chart.” Embarrassed, she cried. Ultimately, an abdominal ultrasound revealed the source of her pain: hepatosplenomegaly. Urgent splenectomy, admission granted. Despite the successful procedure and relief from physical pain, when I visited the patient, she fixated on the exchange from days earlier. “I have a successful job, partner, kids, and a house…and all they see is a dope fiend.…I guess nothing I do matters to you all.” Emotional healing will not be swift.

Assessment: A young Black woman with a trauma history, ADHD, and remote use of substances who is attempting to self-advocate and navigate a health care system that is unkind to people with past substance use.

Plan: Coordinate a team meeting between inpatient and outpatient providers. Stress that the patient’s use of opioids never met criteria for opioid use disorder and occurred more than 5 years ago. Acknowledge that the medical system has historically undertreated Black patients’ pain. Address the inappropriateness of language in her record (e.g., “difficult patient”) that is often used to describe marginalized groups.5

The actual and perceived experiences of Black girls and women involve navigating spaces where their needs are often not addressed; meanwhile, we tend to overlook how well they do so against the odds.

Addressing the conditions Black girls and young women face and protecting their freedom to be themselves requires fundamentally changing the relationships with patriarchal institutions — from education to health care to the justice system — that reinforce their negative experiences. Though equal justice movements and diversity, equity, and inclusion plans aim to protect our children from discrimination, they cannot fully eradicate race- and gender-based inequality. One practice, however, can help us ameliorate its effects, and even I must be mindful of it when engaging my little Black girl — that practice being empathy.

Funding and Disclosures

Disclosure forms provided by the author are available at NEJM.org.

Identifying details have been changed to protect the patients’ privacy.

This article was published on May 28, 2022, at NEJM.org.

Author Affiliations

From the Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, and the Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, and the Department of Psychiatry, Harvard Medical School — both in Boston.

Supplementary Material

References (5)

  1. 1. Simon KM. Them and me — the care and treatment of Black boys in America. N Engl J Med 2020;383:1904-1905.

  2. 2. Fadus MC, Valadez EA, Bryant BE, et al. Racial disparities in elementary school disciplinary actions: findings from the ABCD study. J Am Acad Child Adolesc Psychiatry 2021;60:998-1009.

  3. 3. Blake JJ, Epstein R. Listening to Black women and girls: lived experiences of adultification bias. Washington, DC: Georgetown Law Center on Poverty and Inequality, 2019 (https://www.law.georgetown.edu/poverty-inequality-center/wp-content/uploads/sites/14/2019/05/Listening-to-Black-Women-and-Girls.pdf).

  4. 4. Sheftall AH, Vakil F, Ruch DA, Boyd RC, Lindsey MA, Bridge JA. Black youth suicide: investigation of current trends and precipitating circumstances. J Am Acad Child Adolesc Psychiatry 2022;61:662-675.

  5. 5. Sun M, Oliwa T, Peek ME, Tung EL. Negative patient descriptors: documenting racial bias in the electronic health record. Health Aff (Millwood) 2022;41:203-211.