CHAPTER 1

       JACQUELINE

      When I first met Jacqueline, she was trying very hard to hide in our waiting room. She was wearing large Jackie Kennedy-style sunglasses, and the frayed hood of her hoodie was cinched tightly around her face despite the summer heat. She was wearing gray sweatpants, the cuffs of which were ragged and dingy from dragging on the ground behind her flip flops. Her head was tilted downward, her gaze focused tightly on a spot about six inches in front of her toes. Her mental health assessment noted that she was a transgender woman, but the intake worker did not ask her for her real name. I called out her last name like a drill sergeant and asked her to follow me back to my office.

      I was excited but nervous to begin treating Jacqueline. She was the first patient I had seen with borderline personality disorder, and I had heard horror stories from other professionals about working with that population. She was also the first trans patient I treated. I had no special training in trans health or treating LGBTQ populations, but I was trans-affirming and thought I could help her. Looking back, I think I was also trying to atone for the homophobia and transphobia that had shaded my conservative Midwestern upbringing.

      In my office, I try to create a safe space that comforts the patient. Plants line my shelves, and I have various art prints hanging on the wall, all in muted colors. I keep my lights low. I noticed that Jacqueline continued to keep her sunglasses on her face even though I felt certain she could barely see a thing. She had come ready to begin treatment; she had already called my supervisor several times asking to be connected with an individual therapist. She wasted no time in telling me about her traumatic past. About twenty years ago she was on vacation in her native Brazil visiting her family. At that time she was living as a gay man. She went to a local bar and had a little too much to drink. She met someone and decided to go home with him. He offered to drive her back to his place, and since she had walked to the club she accepted. Due to the lingering effects of the alcohol, the blindness of lust, or both, she didn’t pay attention to where he was going. She noticed when he stopped in the middle of the field, reached behind him, and pulled out a machete. Her senses sharpened, she wrenched open the door and began running for her life. She ran through unfamiliar terrain for an hour and a half until dawn when a stranger let her use their phone.

      I often ask patients when they thought their problems started. I do this not because their answer is necessarily correct, but it gives me a sense of how they think of their symptoms. Jacqueline traced the source of her mental suffering back to that day. It wasn’t hard for me to see why Jacqueline felt that this marked the commencement of her downward spiral. Before then she had lived a decently fulfilling life as a gay man. She had friends, she spent most of her time in Boystown, the historically LGBTQ neighborhood in Chicago, and she was active in the dating scene. Inside she knew that she felt like a woman, and she only really felt comfortable in her own skin when she was performing her drag routine, but she didn’t yet know what it was to be transgender.

      As I grew to know Jacqueline better I found out that things before the attempted murder weren’t quite so sunny as she remembered. She felt immense pressure during high school to act hypermasculine. This grew to be exhausting, and she finally came out as gay to her parents when she was sixteen. According to her they were shocked, but she later told me that one of the first English words her immigrant father learned (and then deployed liberally) was “faggot,” so I assume they suspected something. Regardless, they kicked her out that night. Jacqueline rarely had to sleep on the streets, but sleeping on couches and floors is still no way to live. She worked to make something of herself. She completed a year of college. Later her relationship with her parents healed somewhat, and she was invited back into their circle. She tended to gloss over all of this in session; she lived with her mother and saw her father regularly and reported all was well. I wanted to believe this for her sake, but the wounds of our past often don’t heal as quickly as we would like.

      Jacqueline’s pain didn’t end with her parents. During her twenties she was reasonably well-integrated in Chicago’s LGBTQ scene, and from what she told me it sounded like she had strong friendships. Her romantic relationships were a different story. Nearly every previous boyfriend she recounted to me had abused her in some way—physically, sexually, emotionally, or all of the above. Jacqueline was vulnerable: She had little contact with her family at that time, she worked but still struggled to make ends meet, and she was Latinx in a predominantly white community. I don’t know exactly how this combined to make love so difficult for her. Like many of my other patients, Jacqueline believed that she was just unlucky. Perhaps, but I find it far more likely that her vulnerability, not to mention her growing recognition that she did not belong in a man’s body, made her susceptible to falling for anyone that showed interest in her. Freud believed that we have a repetition compulsion, an inner drive to keep reaching out for the flame even though we know we’ll be burned. I don’t believe in anything that fatalistic, but I do think the past scratches its grooves upon us, and the record keeps skipping unless we move the needle.

      Jacqueline’s first breakdowns began to occur around this point. Nearly every relationship ended with her either calling the police or having her now-ex-boyfriend drop her off at the emergency room doors. None of them accompanied her inside. She turned her pain inward, cutting herself to relieve the pressure that would build. Stress built upon stress, making her more vulnerable by the day. She began to see demons all around her. It was easier to believe that the world was infested by invisible evil rather than to confront the fact that it often shared a bed with her.

      Jacqueline also began mental health treatment at that time. It’s easy to look at her fragile state when she entered my office and conclude that her prior therapists and psychiatrists didn’t do a very good job—and trust me, I’ve thought that too—but I don’t think that’s entirely fair. She achieved some level of stability in her previous clinic, and while I cringed when she told me some of the nakedly transphobic things her old therapist said to her, there were also things she really liked about her treatment there. It was close to her house, close enough that she could overcome her fear of public transportation to ride the bus a few stops to the clinic. She was also able to go there quickly if she was facing a psychiatric crisis, and often just talking to someone there for a few minutes would be enough to stabilize her. Given time, Jacqueline might have perceived the gaps in her treatment and looked for a better fit elsewhere, but she was not given that luxury. Her clinic was run by the city, and it happened to be one of the aforementioned locations quickly shuttered by Mayor Rahm Emanuel. That kicked off another spiral of hospital admissions and near-death experiences. Thankfully she survived. Many others did not.

      There’s a name in hospitals for patients like Jacqueline who frequently make use of emergency services: “frequent fliers.” In some hospital record-keeping systems (not the one I work at, thankfully) their name is accompanied by a small airplane symbol to alert charge nurses and other emergency department staff if they haven’t met the patient at a prior visit. It is helpful to know that the patient