If my wounds were visible

Mrs. Smith smiled openly when I walked into the examination room and introduced myself. A cursory glance at her records showed a healthy female, married, college-educated, nonsmoking. This would be an easy annual wellness check, I thought; a quick in-and-out. While going through her social history, I asked her the same question I ask all my patients: “Do you feel safe in your intimate relationship?” Her smile faded as she averted her eyes and shrank in her chair. I closed my laptop and moved to face her. “You know, intimate partner violence is more common than people think,” I offered. “It's much more than just physical abuse.” After a long pause, I added, “Has your partner isolated you from friends and family?” There was a litany of questions I wanted to ask, but they required care. “Has he denied you access to family finances...? Repeatedly lied to you or hidden his activities...? Pressured you to engage in sexual activity...? Does any of this sound like something you may have experienced?” “He's never hit me,” she offered quietly. “But have you felt afraid in other ways?” I asked. From there came an outpouring of confessions, a retelling of instances that had long left her confused. Her husband was a public figure, one who knew how to deliver speeches and charm crowds, but he became a different person in the privacy of their home. He would often criticize and belittle her. She had no knowledge of their finances because he denied her access to their bank accounts, instead giving her a monthly allowance while he spent freely. He was secretive with his phone and evasive about his daily whereabouts, yet possessive of her time: he became angry when she wanted to visit the family of her late best friend, telling her, “I don't understand why you need to go over there.” He would erupt in rage whenever she confronted him about a lie, frightening her into silence. She recounted an instance of marital rape and said she never said “no” again. And yet there were also times when he would offer grand, public displays of love and affection. She told herself that no marriage was easy, and besides, he never hit her. Yes, she had made attempts to leave, but he either promised to change or made veiled threats, so she stayed because that seemed the best path for peace and security. Not all wounds are visible. Violence often occurs in ways that cannot be seen, in the form of emotional, financial, psychological, or sexual abuse.1 Do we, as providers, fully understand what safety in a relationship means? Do our patients? These other, often coexisting, forms of violent control that cannot be seen make it difficult for a victim to both acknowledge a hard reality and to find the resources and resolve they need to leave an abusive relationship.1 Following up a question about feeling safe in a relationship with one on physical abuse merely distills the breadth of intimate partner violence (IPV) down to the only form that shows external evidence. IPV occurs across all races, ages, socioeconomic statuses, cultures, and education levels.1 Abuse in all forms can result in posttraumatic stress disorder, depression, and anxiety, in addition to the long-term physical sequelae of cardiovascular disease, substance use disorders, and chronic inflammatory diseases.1-3 Globally, 27% of women and girls have experienced or are experiencing some form of IPV.1-3 This population includes not only our patients, but also our friends, family, colleagues, and, yes, perhaps even ourselves. Leaving is never easy. It takes victims of IPV an average of seven attempts to leave before they can stay away for good. Recognition and acknowledgment are the first steps toward freedom. Mrs. Smith did find hers. With support from her therapist, friends, family, and a skilled attorney, her sixth attempt at leaving her marriage succeeded. If you or someone you know is concerned for their safety in their relationship, the National Domestic Violence Hotline is available by phone, webchat, and text 24 hours a day, 7 days a week. Visit www.thehotline.org, call 1-800-799-SAFE (7233), or text “START” to 88788.