*Contains spoilers
When I first read Patricia Cornwell's The Body Farm in the 1990s, I was a medical student and a young mother. Given those roles, the reveal of the killer was not a solution in my lexicon -- Munchausen syndrome by proxy was rarely discussed in medicine. It was also the first popular crime novel to feature Munchausen by proxy. Looking back now, after we've all been educated about the syndrome, it might seem like an easy solve. But it is precisely because The Body Farm came out 3 decades ago that we collectively found it an easy solve today. It was no easy solve then. It is still a huge stretch for doctors to consider, let alone investigators.
Munchausen by proxy is a term derived from Munchausen syndrome. Baron von Munchausen was said to be a German cavalry officer in the 18th century, widely known for his untruthful but dramatic tales of his mythical travels. In 1951, the term Munchausen syndrome was used to describe the fabrication of medical symptoms, which could lead to hospitalization and unnecessary surgery. In 1962, the term "battered child syndrome" was coined. Yet, even in the present day, many cases of child abuse are still missed. When studies ask adults about abuse histories, they find that only one-tenth of abuse cases were captured in official rates. Doctors must be willing to consider child abuse in their differential diagnostic thinking -- which goes against how doctors want to think about the parents of patients. After all, what could lead mothers to abuse children they were meant to nurture and love?
In 1977, the term Munchausen syndrome by proxy was first described: a parent purposefully feigning medical symptoms in their child, harming their child, in order for that parent to get the desired attention. In a whopping 95% of cases, that parent is a mother. And she's often involved in the healthcare profession. Over the years, the preferred terms have changed from "factitious disorder by proxy (or imposed on another)" to "fabricated or induced illness by carers" to "medical child abuse."
This latter term -- medical child abuse -- feels especially fitting because this behavior, whatever the psychological reason behind it, is without a doubt abuse of a child. It's important for health professionals to keep this top of mind; a parent may present as nice or normal, and it may be difficult to image why a parent would harm her child, but it does happen. Rather than focusing on the question of "What kind of mother would do that?" we should be focusing on the action -- the harm of the child.
Several books and movies in pop culture remind us to focus on the child.
Those who read or watch true crime will remember the recent case of Gypsy Rose Blanchard (in the documentary "Mommy, Dead and Dearest" and its dramatization in "The Act"). But arguably, it's the crime fiction arena that has brought this rather unbelievable behavior into the public conscience more than anything else. When forensic psychiatrists testify about the state-of-mind of the perpetrator or pediatricians testify about medical child abuse in these cases, much of what the jury or judge knows may have come from crime fiction. As fiction readers, we suspend our disbelief. That is why in the real courtroom, after real medical child abuse was potentially perpetrated by the person sitting in front of them in the witness stand, it can be hard to fathom.
Six more fictional thrillers trace the portrayals of medical child abuse in crime fiction, helping to open our collective eyes about this crime.
In Devil's Waltz, Jonathan Kellerman's seventh novel featuring forensic psychologist Alex Delaware, the protagonist faces a medical mystery. Cassie is 21 months old when she is rushed to the emergency department with unexplainable symptoms. Her parents are devoted, and so is her nurse. A doctor caring for Cassie is killed, and it eventually becomes likely that one of the parents or the nurse is actively inducing the baby's illness.
"Sharp Objects," a fairly recent HBO miniseries, was adapted from a 2006 novel of the same name by Gillian Flynn, who would go on to write the breakaway thriller Gone Girl. In "Sharp Objects," Camille Preaker is a journalist whose eldest sister had died after suffering a lengthy illness. Her mother was all about the attention. The nurse who spoke up about her concerns was silenced and mocked by her superiors.
Saving Meghan is a medical thriller by DJ Palmer, son of Michael Palmer. The teenage titular character, Meghan, had been a star soccer player. She develops symptoms of weakness, fatigue, headaches, and loses her appetite. Meghan's mother is preoccupied with her health. Is she the loving mother she appears to be, or is she a perpetrator of medical child abuse? Or is Meghan herself creating the symptoms? In this novel full of twists, the focus is on the act of the medical abuse itself, rather than too deeply probing the perpetrator's mind.
Darling Rose Gold and Grace Is Gone both appear to have taken inspiration from the Gypsy Rose true crime case. Darling Rose Gold imagines the aftermath of a medical child abuse case, and the relationship a mother and daughter might share later. In Grace Is Gone, bedridden Grace goes missing. Grace's well-loved mother, who the town has helped through fundraising and other acts of kindness, is later found bludgeoned in her bed. This story parallels that of Gypsy Rose, who indeed had none of the illnesses that her mother reported; the mother received trips to Disney and a home from Habitat for Humanity because of her (not) sick daughter, and then was later killed when Gypsy Rose was finally escaping the medical child abuse. When books draw from true crime, there is a risk of sensationalizing horrors of abuse; but Grace Is Gone avoids this by delving into a character personality study and considering how these cases might go about undetected.
In The Appeal, Martin and Helen are crowd-funding treatment for their granddaughter Poppy's cancer treatment. Sam, a nurse, announces that the doctor fraudulently wants the money for treatment paid directly to her. Sam suddenly and unexpectedly meets her end. In the end, we learn that making one's child ill for attention is something that not only mothers might do, but fraud from health professionals can factor in too.
Several of these examples bring up the question of whether parents guilty of medical child abuse are doing it for the attention of doting on their sick child or for the substantial financial benefits in some cases. Furthermore, these thrillers go beyond the idea that only a parent could purposefully medically harm a child to also explore what other perpetrators might be involved.
Doctors and nurses play important roles in sounding the alarm that a child's disease does not fit into standard medical knowledge -- and we must be willing to consider a diagnosis of medical child abuse when appropriate. These crime thrillers helpfully draw our focus away from the psychology of the abuser and toward the critical reality of the victimization of the child. Legal adjudication and treatment of the parent must be conceptualized differently than suspecting abuse and diagnosing the child accordingly.
As healthcare professionals, we should heed the lessons from crime fiction that protecting the child from the behavior -- rather than focusing on understanding the mind of the perpetrator -- is the most critical.
Susan Hatters Friedman, MD, is the Phillip Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland, Ohio, where she is also professor of psychiatry, reproductive biology, pediatrics, and law (adj).