The countless episodes of violent, sexual assault and torture visited upon Jude as a child, adolescent, and later as an adult will test any reader’s stamina on both emotional grounds and measures of credulity. For those with the stamina to read through most or all of the book, however, it provides compelling insights on certain illness experiences. In particular, pain, self-cutting, and a neurodegenerative rare disease are covered. Suffering suffuses the novel.  

Apprehending the pain someone is experiencing can be difficult for others who are not experiencing it. Elaine Scarry (1) has attributed this problem in large measure to difficulties people in pain have in expressing it: “physical pain does not simply resist language but actively destroys it.” (p. 4) As a result, she goes further to say, “to have great pain is to have certainty; to hear that another person has pain is to have doubt.” (p. 7) Among various sources for language to use for pain, Scarry cites “art” and in particular “fictional analogs, perhaps whole paragraphs of words, that can be borrowed when the real-life crisis of silence comes.” (p. 10) Yanagihara provides such a fictional analog in describing an episode of pain Jude experiences while witnessed by one of the roommates, Willem:  

They were talking, but Jude’s eyes were closed, and Willem knew—from the constant, hummingbird-flutter of his eyelids and the way his hand was curled into a fist so tight that Willem could see the ocean-green threads of his veins jumping under the back of his hand—that he was in pain. He knew from how rigid Jude was holding his legs, which were resting atop a box of books, that the pain was severe, and knew too that there was nothing he could do for him. (p. 21)   

Using this fictional analog, Yanagihara imagines how people can know others are in pain without doubt.  

Jude’s obsession with cutting himself is refractory to all admonitions, interventions, and close calls. The people in his orbits are at their wits end. While eventually some of them almost come to accept it, none of them ever understands why he does it and remain forever horrified and afraid for his life. Biomedical texts offer explanations such as the following (2):  

Recent evidence suggests that biological factors may contribute to the act of self-mutilation. These factors suggest a biological vulnerability for engaging in the behavior either due to a dysfunctional neurotransmitter system or an abnormal psychophysiological response to self-mutilation that involves tension reduction. (p. 172)    

The biomedical explanation is technical, vague, and certainly not illuminating or particularly memorable. In contrast, Yanagihara, through an explanation Jude would have liked to make to Willem, if only he could, provides a more compelling and elaborated explanation of what can motivate self-cutting:  

You don’t want to see me without it, he wanted to tell Willem, as well as: I don’t know how I’d make my way through life without it. But he didn’t. He was never able to explain to Willem what the cutting did for him in a way he’d understand: how it was a form of punishment and also of cleansing, how it allowed him to drain everything toxic and spoiled from himself, how it kept him from being irrationally angry at others, at everyone, how it kept him from shouting, from violence, how it made him feel like his body, his life, was truly his and no else’s. (p. 555)  

Yanagihara’s fictional account provides a much deeper understanding of what can drive self-cutting behavior. She refers to particular emotions rather than unspecified neurotransmitters, and she points to specific outcomes sought rather than to psychophysiological domains involved. She goes further to introduce a rationale about how self-cutting helps not only the cutters, but how the cutters can imagine it helping others around them.  

The novel includes a brief but poignant part that provides a view into what parents can go through when they have a child with a rapidly progressive and fatal rare disease. Harold, Jude’s adoptive father, tells of the searing loss of a child many years before. The child was stricken when he was an ostensibly normal four-year-old, and within a year progressed from lethargy initially, then seizures, immobility, blindness, speechlessness, and finally to death. Many first-hand biographical accounts of this type of loss have been published, and they serve a very important purpose. However, they tend to be straightforward, chronological details of these experiences. In the hands of skilled writers, these stories can do more than prompt a mere nod of familiarity. Consider Yanagihara’s description of Harold and his wife’s (Liesl) travails finding a doctor who could diagnosis their child (Jacob) as they watched him deteriorate further and in spite of Liesl’s knowledge as a physician:  

And then began the months of going from one doctor to the next, of having Jacob’s blood drawn and brain scanned and reflexes tested and eyes peered into and hearing examined. The whole process was so invasive, so frustrating—I had never known there were so many ways to say ‘I don’t know’ until I met these doctors—and at times I would think of how difficult, how impossible it must be for parents who didn’t have the connections we did, who didn’t have Liesl’s scientific literacy and knowledge. But that literacy didn’t make it easier to see Jacob cry when he was pricked with needles, so many times that one vein, the one in his left arm, began to collapse, and all those connections didn’t prevent him from getting sicker and sicker, from seizing more and more, and he would shake and froth, and emit a growl, something primal and frightening and far too low-pitched for a four-year-old, as his head knocked from side to side and his hands gnarled themselves.” (p. 389-90)  

People with rare diseases often speak of the diagnostic “odyssey” they experienced before they finally learned what was causing their illnesses. Left to Yanagihara, the diagnostic odyssey becomes better understood as Homeric in the torrents that threaten to capsize their hopes, the strange and unknown clinics they are sent to visit, the seductions of unproven treatments they can barely resist, the monstrous bureaucracies they encounter, and the constant fear that they will never receive a diagnosis for their illnesses.   

Readers interested in the insights this novel offers on illness experiences may not be able to tolerate all the violence and assault that comes with them; rewards are available for those who can persevere. Those yet interested in insights on suffering more generally will also be rewarded. Few characters in the novel escape any significant suffering, and none more so than Jude whose suffering reaches biblical proportions. However, only Jude beseeches a god for relief or explanations, “a god he didn’t believe in,” and only once. (p. 442) Readers will still have to turn to Dostoevsky and other writers for theological insights on suffering rendered through literary fiction.      

1. Scarry, E. The Body in Pain: The Making and Unmaking of the World. Oxford: Oxford University Press, 1986.
2.Messer JM, Fremouw MJ. A critical review of explanatory models for self-mutilating behavior in adolescents. Clin Psychol Rev 2008;28:162-78.