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A 25 year old African American pt stopped by today for a doctor’s note. This is one of the most common reasons for visits here. She stated she got into an “altercation” four days prior. Pt remained vague on the details of this altercation, or who it was with. She did not seek medical attention at the time. She stated that she wants time off because her injuries still hurt. Pt is downcast and on the verge of tears. She says the injuries consist of bruises. She denies any loss of consciousness, dizziness, change in vision or hearing, weakness, numbness.

Examination shows healing bruises on both upper arms. Pt is an expert at makeup, but shows me a photo on her phone of a black eye. No other injuries were evident.

I WAS 100% SURE OF THE DIAGNOSIS AS SOON AS I WALKED IN THE DOOR. WHAT IS YOUR GUESS?

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Contusions secondary to domestic violence

Few cases are as emotionally difficult for me as these.

The history obtained by the staff told me most of the story before I even got out of my chair. The incident happened four days ago — delay in seeking care is characteristic, as patients know full well the questions they will receive if they rush to the ER. And the wanting a doctor’s note four days after the injury was obvious bullcrap.

The ugly bruises on the upper arms are characteristic of being grabbed forcibly, probably to be shaken. As mentioned, she was great at her makeup game, but she wanted to show me her black eye anyway. Even if they have no intention, or ability, to leave their abusers, victims of DV often wish to have their pain acknowledged by some third party or authority figure.

Not that they would leave. Physical abuse typically happens in a scenario where total dominance has already been established, usually either psychological or financial, or both. Thus, the victim often quite literally cannot even imagine life without the abuser.

I mentioned how emotionally difficult these cases are for me. Let me explain why.

I wish I could get on my pulpit and declare it’s because I am somehow so unusually more moral and empathetic than thou. Sure, I sympathize, but I also sympathize with cancer patients and dialysis patients and patients with all kinds of dreadful conditions that show up on my blog. No… I go beyond sympathizing with this patient. I empathize because I was there myself.

Not with the beatings. Thank God. So I generally don’t ever try and compare what happened to me to what happens to female victims of DV.

But the utter and complete control by a person who is alternately kind and vicious; caring and abusive; able to build you up one day with the most love you could ever imagine, followed by the most malign psychological take-down imaginable by a professional torturer… the nightmares, the continued paroxysms of self-loathing, the feelings of worthlessness, the wrecking-ball to the confidence… four years were taken from me that I will never get back and with incalculable damage inflicted, and seeing a fellow human being going through this torment fills me with grief for both her and for myself.

Other characteristics the abuser tends to check off their list: total isolation of the victim from their friends and family; insults and put-downs, often gender-based; gaslighting (making the victim believe they are the crazy one); complete control of finances and income, no matter which partner is working; intense jealousy and projection; wanting full access to all the victim’s email and social media accounts; making all of the decisions. My ex scored 100% on this test, and I would not be surprised if my patient’s boyfriend would pass the test with a B+ at least.

Again, I am fortunate in my birth gender (and sexual orientation; DV is a real thing for gays and lesbians) that I was immune to physical abuse. But even female DV victims generally do not reach that stage without the above psychological and emotional dominance achieved first — otherwise, the victim would have no qualms going to the cops or leaving him, as the abuser knows.

My abuser was possessed with an utter and unassailable conviction in her own moral worth that is frankly alien to other women, who are taught to continually reassess and self-judge their character. But a sociopathic inability to look inward as such is actually an alpha personality’s greatest strength. It allows them such great power without the chains of self-doubt, and also allows them to commit such great evil for the same reason.

I wish there were just some way to reach my patient today, just as I wish there were some way for my own family to have reached myself. Lord knows, they tried and tried. And so I have tried and tried in my practice. With equally pitiable results.

The authorities in my jurisdiction generally won’t bother with a DV case unless the victim wants help. If she does want help, yes, the resources available to her are generous. (I live in a blue state.) But if she does not wish to help herself, the authorities simply won’t bother. And believe me, I have tried. Giving her the right phone numbers won’t help. (Do you really think she will call?) Calling the right numbers myself, and then handing the phone to her, won’t help. (Do you really think she will keep her appointments?) Calling the cops, with the perpetrator physically sitting in my clinic when they arrive and with obvious and easily photographed injuries on her person, achieves nothing. (Do you really think she will press charges?)

The most remarkable thing, though? They still come to my clinic.

Even though they will never admit to anything, they are able to acknowledge that something is very, so dreadfully wrong with their health. And so they follow the natural instinct of the sick individual, which is to try and find a doctor. As mentioned, they at least want to have their pain acknowledged by an authority figure. That is the limit of what they do, because they’ll lie their asses off once they’re in the exam room… but it’s something, at least. Part of their brain will at least get them as far as the ER or the urgent care, even if they then quite literally cannot imagine life without their abuser. Which I fully empathize with.

The patient I saw today was nowhere near her breaking point. It took four years to reach mine, and unfortunately I understand. Freaking armed federal agents could have dragged her away and put her under witness protection for her own good, and she would think about nothing but how to break out get back to her abuser. Because he is everything for her. Everything.

I am so sorry for my patient today that I could not help her, but I understand. Because no force on this planet could have helped me either.

I mentioned DV in gay and lesbian relationships. One situation in my clinic involved a classic “butch” lesbian and a girly, lipstick-wearing, feminine “femme.” Both were there, and the abuser was obviously controlling the conversation and the victim was pliant and quiet while I examined the bruises. There was no question who was dominating whom. And the picture in your head is completely wrong: The perpetrator was the femme and the victim was the butch. It broke my heart.

If you feel yourself slipping into the sinkhole where nothing even exists outside your relationship partner, please get help before it is too late. An overview of DV can be found here. The National Domestic Violence Hotline may be found here. Please be aware that these will show up on your browser history, so invoke privacy mode (Ctrl+Shift+N for Chrome; Ctrl+Shift+P for Firefox) before proceeding. It doesn’t have to be like this.

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