Everyone knew when Tanya was in my office getting a pap smear or having a gynecological problem. Her scented perfume of a Hawaiian vacation was noticed by everyone, including those patients in my waiting room. She was always coming from a Soul Cycle workout dressed in the perfect workout ensemble and pristine Nike shoes that always looked brand new. Even though she was 43 years by birth, she really didn't look a day over 30. It might have helped that she has been getting monthly Botox and Juvederm injections. Tanya had a gentle smile and warm hug every time I saw her.

During this visit, she came in complaining of painful sex with her husband of 4 years. We went through the typical questions. "It is positional pain? Are you wet enough? Are you having regular weekly sex? Are you having any vaginal discharge or odor?" (Common reasons women have pain with sex).

"My pain with sex is not related to any of those issues," she said.

I asked her, “Are you having orgasms?" and she said no, she rarely does with her husband, and she went on to blame herself.

At her third visit with me for the same problem, I asked about her relationship with her husband. As tears filled her eyes she admitted he wasn't the man she married. He had been verbally abusive to her for a long time. Tanya said, "I really thought it would get better, but it hasn't, in fact it's gotten worse."

As I listened to her I finally asked, "Has he ever hit you?" She paused for what seemed like hours before she bravely nodded her head and from there the real conversation started...

With October being Breast Cancer Awareness Month, I have to admit that even as a Gynecologist I wasn’t aware this month had even greater significance for women. October is also Domestic Violence Awareness Month.

Domestic violence is defined as the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. It can include physical violence, sexual violence, psychological violence, and emotional abuse. There are many ways an abuser can try to control another person’s life.

The one constant aspect of domestic violence is one partner's continual efforts to maintain power and control over the other. There is no "typical" abuser. There are no universal characteristics about a person that can alert you to who is more likely to be "that" kind of person.

Domestic violence doesn't discriminate. It affects people regardless of age, background, economic or educational status, sexual orientation, race, religion or nationality. Nearly 3 in 10 women and 1 in 10 men in the US has experienced rape, physical violence or stalking by a current or former sexual partner.

The truth is that domestic violence is difficult to detect in the early stages of a relationship. It may be subtle in the beginning, but over time the signs become clearer. Emotional and psychological abuse can be present with or without physical abuse, but can escalate to violence at any time. Abusers may start as the picture perfect partners and yet over time aggressive and controlling behaviors become more evident.

The abuser is classically the one who wants to be in control - the constant source of power in the relationship. One of the ridiculous myths of domestic violence is assuming the person being "victimized" had low self-esteem or lacked self-confidence. Victims of domestic violence DO NOT bring violence upon themselves or "ask for it." Low self-esteem or self-confidence is the result of the abuse, not the cause.

Warning signs or red flags of abusive behaviors - which can escalate at any time - include:

• Telling the victim that they can never do anything right
• Showing jealousy of the victim’s family and friends and time spent away
• Accusing the victim of cheating
• Discouraging or preventing the victim from seeing friends or family members
• Embarrassing or shaming the victim with put-downs publicly or privately
• Controlling every penny spent in the household
• Taking the victim’s money or refusing to give the person money for expenses
• Looking at or acting in ways that scare the person they are abusing
• Controlling who the victim sees, where they go, or what they do
• Dictating how the victim dresses, wears their hair, etc.
• Stalking the victim or monitoring the victim’s every move (in person or also via the internet and/or other devices such as GPS tracking or the victim’s phone)
• Preventing the victim from making their own decisions
• Telling the victim that they are a bad parent
• Threatening to hurt, kill, or take away the victim's children
• Threatening to hurt or kill the victim’s friends, loved ones, or pets
• Intimidating the victim with guns, knives, or other weapons
• Pressuring the victim to have sex when they don’t want to or to do things sexually they are not comfortable with
• Forcing the victim to have sex with others
• Refusing to use protection when having sex or sabotaging birth control
• Pressuring or forcing the victim to use drugs or alcohol
• Preventing the victim from working outside the home or attending school
• Harassing the victim at work or at school
• Sabotaging the victim's efforts at work or at school, such as by keeping them up all night so they perform badly
• Destroying the victim’s property
• Showing signs of extreme jealousy, possessiveness, unpredictability, a bad temper, cruelty to animals, controlling all the finances, abuse to other family members and children and embarrassment or humiliation of the victim in front of others

The first step in escaping an abuser is to talk to someone you trust. The trusted person can be a health care profession, social worker, clergy member or close friend or family member.

If you believe that someone you love is being abused, let them know you are a safe person to talk to. Understand that they are the best judge of their own safety and don't pressure them to leave until they are ready. Leaving an abuser is extremely dangerous. Help them to make a safety plan for themselves and their children.

If you are being abused, leaving your partner is not about breaking up as much as it is about safely escaping the abuse. Make a safety plan for yourself and your children, and learn about discreet browsing on the internet for while you are planning your escape.

No one deserves to be abused under any circumstances. When there is emotional, sexual, or physical violence in a relationship the only person to blame is the person being violent, NOT the victim.

Tanya turned her life around, and so can you.

If you are experiencing any of these circumstances in your relationship, it’s time to have a real conversation with someone you trust or call the National Domestic Violence Hotline at 1.800.799.SAFE (7233).

References and Additional Information

National Coalition Against Domestic Violence. What is domestic violence?  http://www.ncadv.org/need-help/what-is-domestic-violence Accessed October 28, 2015.

National Network to End Domestic Violence. Domestic violence doesn't discriminate. http://nnedv.org/getinvolved/dvam/1558-dvam-blog-series-5.html Accessed October 28, 2015.

The American College of Obstetricians and Gynecologists. Domestic violence FAQ. http://www.acog.org/-/media/For-Patients/faq083.pdf?dmc=1&ts=20151014T2142251659 Accessed October 28, 2015.