http://www.nytimes.com/2019/03/14/opinion/suicide-prevention.html?comments#permid=31069462

After they are dead, I will go into their rooms to smell them. As if to remind myself that each one is a separate individual. I put his pillow in my face and breathe him in deeply. I crawl naked into his bed. I finally sleep. The days after he dies, I am needed 24/7.

I teach adolescent boys with HIV. They are called the Hard To Reach. All of them are poor. There are no percentages. All of them have been sexually abused. Exploitation is normal.

I don’t write about it anymore. Writing is a wrestle with extraordinary futility and indifference. There is no point to writing about it. There is no clarity. There is no closure. There is no understanding. Writing (like this) is a waste of my time. I am needed elsewhere. If I am having a hard time with sudden death, how can you or I possibly know what a fourteen-year-old is feeling. They don’t bond easily. It is forced upon them by life. They are afraid their new friends will die, and they are right to feel that. They shy away. They live in their own twisted worlds.

They might stand on a corner somewhere, smoking cigarettes in the rain, but when the trick fucks them, they will be alone.

Simple: I keep them busy. We make videos. We film them, add to them, and edit them. As an art entity, we claim fair use. If I can keep them engaged, I can keep them alive. I usually have about one day to make a video. The process cannot be slow. We throw our videos together, and then move on to the next one. We have so far made 3,179 videos. You may not see it in the context of the video, anymore than you would see it in the child, but suicide is always there.

In a touch. In a glance. In the running from something. Monsters. In our indifference to them, they do not exist. We turn them into monsters.

They are not monsters.

They are as individuals trying to cope.

Do NOT talk to me about medication because there are none that can do the job. Do NOT talk to me about brain development because knowing everything about serotonin up-take does not help. Antidepressants do not help. Waiting two weeks for the drug to kick in is patently absurd and statistically beneath contempt. We hide among the statistics. Homo sapiens have evolved cultural censorship when it comes to suicide because if we didn’t, the tribe would face extinction.

I have to find a thousand ways to say: I Love You. I have to mean it. Even if I do not know you, I love you with 100% unconditional regard anyway. It isn’t easy. But it is required. I have to find a million ways to say We Can Do This Together. We can survive together.

They do not believe it. There are no romantic options. Only reality. Cold as naked in some dead kid’s bed.

Smell this dead kid. From the day he was born, each infant smells differently.

Smell his underpants.

Wear his clothes.

I never pull my writing punches. I don’t give a fuck how you feel about it. You don’t like it, don’t read it. You can’t handle it, go home. Please, go home. Get the fuck out of my way. I cannot use your nice reticence and I don’t want it anywhere around us because it is exactly THIS undemonstrative body language, this dirtiness, this hanging by the neck, this modest restraint that is INAPPROPRIATE.

NOT sleeping in his bed or, more likely, his sleeping bag. Is inappropriate.

I bought that sleeping bag.

I own it.

Sleeping in it is to know his drowning. I am compelled to know how he drowned because maybe, just maybe, there is some small chance I can prevent it with someone else.

I can convince myself of this, but let’s be real. I am doing this for me.

STOP. STOP. Stop telling me I didn’t fail the dead kid.

I FAILED him and there it is.

The ones who are still alive are doing sex work. I know they share their money. I know sex work. I know the smells it comes with. We use these boys. We seduce them. We rip them off. We rape them. Keeping them alive takes more than community. It takes laws. It takes education. It takes money. It takes grit. It takes a willingness to do more than call 911.

This from the NIH.

Approximately 75% of suicides occur in low- and middle-income countries (LMICs) where rates of poverty are high. Evidence suggests a relationship between economic variables and suicidal behaviour. To plan effective suicide prevention interventions in LMICs we need to understand the relationship between poverty and suicidal behaviour and how contextual factors may mediate this relationship. We conducted a systematic mapping of the English literature on poverty and suicidal behaviour in LMICs, to provide an overview of what is known about this topic, highlight gaps in literature, and consider the implications of current knowledge for research and policy. Eleven databases were searched using a combination of key words for suicidal ideation and behaviours, poverty and LMICs to identify articles published in English between January 2004 and April 2014. Narrative analysis was performed for the 84 studies meeting inclusion criteria. Most English studies in this area come from South Asia and Middle, East and North Africa, with a relative dearth of studies from countries in Sub-Saharan Africa. Most of the available evidence comes from upper middle-income countries; only 6% of studies come from low-income countries. Most studies focused on poverty measures such as unemployment and economic status, while neglecting dimensions such as debt, relative and absolute poverty, and support from welfare systems. Most studies are conducted within a risk-factor paradigm and employ descriptive statistics thus providing little insight into the nature of the relationship. More robust evidence is needed in this area, with theory-driven studies focussing on a wider range of poverty dimensions, and employing more sophisticated statistical methods.

They kill themselves all the time. I am now used to it. In the underworld they live in, guns are popular. I have come to find out they all have one. Hidden somewhere.

Yes, guys, I know because I know everything including how you smell.

All of them are at risk. All of them have tried before. In order for them to get HIV meds from Public Health, they are required to undergo vigorous physical examinations. These are survivors of sexual violence. On the way home, all of them are – always – mute.

They are subjected to being raped all over again and again and again. I could not do it. I could not do what they are required to face. I would kill myself. We want them to live for us. “Normal people” take the physical exam for granted. But not these boys. Anal gonorrhea is as common as the stink from it. Every single boy who does sex work will have the papilloma virus and anal warts and it can kill him. You are thinking: if they can tolerate sex, then why is it so difficult for them to endure a physical examination.

Say what.

It has to do with being reduced to the status of an object, rage, they hate sex. They hate people, and they hate themselves. I cannot change these problems for them, I can only shove and push them hard in what might be the “right” direction.

They are in denial about having HIV. They are in denial about anal gonorrhea even though they reek with it, and cramps them up into a fetal position. (“I’m fine.”) They are in denial about the human papilloma virus being lethal. They are in denial about not seeing past what tomorrow might be. They are in denial about suicide being something you cannot come back from. After tolerating the inevitable physical exam, they are commonly mute for days, and the days and nights of support have to begin again. It’s like being pushed back from some place where they were reaching for the ability to thrive. Then, the physical exam happens, and they are back to square one. They call it Being Still While Getting Finger Fucked.

The cycle itself will wear you out. The medical community is to blame. What they do is punish these boys for something that is our fault. Deeply endemic intractable poverty.

All of them are at risk. All of them have tried to kill themselves before. In order for them to get the miracle HIV meds from Public Health (something they are not convinced they have to do), they are required to undergo vigorous physical examinations that are simply way too tough. These are survivors of sexual violence. We unequivocally refuse to recognize that. On the way home from public health, all of them are – always – mute. They are subjected to being raped all over again and again and again.

I could not do it. I could not do what they are required to face. I would kill myself. We want them to live for us. Us. Us 

Self-interest

We matter.

What they need is irrelevant.

“Normal people” take the physical exam for granted. But not these boys. They are commonly silent until it comes screaming out, and the days and nights of support have to begin again. It’s like being pushed back from some evolutionary place where they were reaching for the ability to thrive. Then, the physical exam happens, and they are back to square one. The cycle itself will wear you out. The medical community is under no obligation to explain itself. There is not a thing transparent about it. Public Health is poverty care and it shows. A Public Health doctor will see over 65 patients a day. It will grind you into pencils. The medical community itself is to blame. It reflects our values or lack of them. What they do is punish these boys for something that is our fault. Deeply endemic intractable poverty.

This is not unlike the tricks, all family men, deeply, endemically intractable.

Poverty and homelessness scares us. So does sex.

How do you think they feel being kicked out of the family home for the crime of being gay.

The LGBT community has made so much progress. But these boys do not belong to this. Gay men are terrified of these boys. They are acting up. Many deny being gay. Awareness comes when awareness comes.

Suicide prevention has been highlighted as a global public mental health issue by the recent World Health Organisation report on suicide (WHO, 2014) and the United Nations proposal to include suicide rates as a key indicator for target 3.4 of the Sustainable Development Goals. Suicide is the tenth leading cause of death globally (Hawton & van Heeringen, 2009) and it is estimated that as many as 804 000 suicide deaths occurred worldwide in 2012 (WHO, 2014). It is estimated that rates of non-fatal suicidal behaviour are 20 to 30 times more common than completed suicides (Wasserman, 2001). In Ireland for instance in 2013 rates of self-harm for men were 182 per 100 000 and for women 217 per 100 000, which is higher than the suicide rates of 17.4 and 3.9 per 100 000, respectively (Griffin et al. 2015). For every suicide attempt an estimated 10 people experience suicidal ideation (Borges et al. 2010). As many as 75.5% of suicides occur in low- and middle-income countries (LMICs) (WHO, 2014). A large body of evidence documents the psychiatric risk factors for suicidal behaviours (Hawton et al. 2005a, b; Krysinska & Lester, 2010). A growing body of literature documents the relationship between suicide and socio-economic variables, such as poverty, financial crisis, indebtedness and unemployment (Brinkmann, 2009; Fliege et al.2009; Platt, 2011; Chan, 2013; Coope et al. 2014; Haw et al. 2015). The recently published systematic review of 37 studies utilising multivariate analysis of the relationship between poverty and suicidal ideation and behaviours in LMICs, is a further example of literature in this field (Iemmi et al., 2016). Understanding relationships between poverty and suicide is important for suicide prevention, especially in LMICs where rates of poverty and suicide are high and where the economic costs of suicidal behaviour are substantial. It is within this context that we conducted a systematic mapping of the literature published in English on poverty and suicidal behaviour in LMICs. Our intention was to consider critically what has hitherto been the focus of research on poverty and suicidal behaviour and identify possible future directions for research. We focused on methodological issues (such as measurement, study design, methods of statistical analysis and theoretical frameworks) employed in the published English literature, with a view to making suggestions for how future research in this field might be strengthened in order to make meaningful contributions to suicide prevention in LMICs.

The NIH is of no help to me. HIV is stigma. Poverty is stigma. Suicide is stigma. I would argue that on a good day, it’s about survival. It is about survival.

As I write this, they are asleep. The house is dreaming of their humid smells. We will be throwing a video together today. My cameraman needs a one-on-one. You want to fight with a school district. Ask for a one-on-one. 

Another boy, usually an older boy, will be his one on one. I don’t have time to fight with administrators because that would be all I would do. My time has to count. I am ruthless about my time. I sleep in dead kids’ beds. And the older boy who will become the one on one, will learn something from it, too.

Breakfast will be where they decide what their video will be about. It could be about dogs. It could be about smoking weed. It could be about pain. It could be about sailing to England, Baby, maybe to spain. By mid-morning, they will know. I will be doing laundry.

Good or bad. Long or short. It’s harder to do making any form of art – than you think. It involves math, an arch, storytelling, script writing, poetry, art, communication, collaboration, and STOP telling me that learning can’t be fun. I am sick of hearing it, and I am not listening.

They will go to bed tonight tired and exhausted. I want them to.

If you end up watching their video, go ahead and breathe it deeply in. Crawl into bed with it. It might be the last thing some mysterious, silent kid ever does.

Addendum:

I have tried answering the readers’ questions at the New York Times in the reply section.

Many (most) issues here in Appalachia exist because this is Appalachia. HIV and sex work would just be two of those issues. Not much effort is made by the community to explore these issues because in Appalachia, we have a fundamentally religious view that would punish sex workers and anyone with HIV. This righteousness seeps into every ignorant crack of Appalachian life. It doesn’t matter if you are educated and a professional. Racism is the skeleton we hang out hats on. This is how it works.