Rob Porter. Photo via AP

“Rob Porter is a man of true integrity and honor,” White House Chief of Staff John Kelly said in a statement earlier this week. Kelly was defending former White House aide Porter, who resigned last week after two of his ex-wives, Colbie Holderness and Jennifer Willoughby, detailed his physical and emotional abuse to the Daily Mail.

In separate interviews, both of Porter’s ex-wives have described in detail a range of intimate partner violence, including punching, kicking, verbal abuse, and controlling behavior. The photographs of Holderness’s black eye, taken while the then-couple were vacationing in Florence, Italy, were published on multiple platforms and treated as indisputable visual evidence of abuse, another of Holderness’s allegations was less remarked on but far more serious: choking.

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Holderness told the Daily Mail that during their marriage, Porter’s physical violence escalated to choking. “It was not hard enough for me to pass out but it was scary, humiliating and dehumanizing,” she said in the interview. Though Holderness used the term “choking”—a common expression that, in context, describes the act of manually applying pressure to a neck—domestic violence advocates prefer the term strangulation (or, non-fatal strangulation). “Choking is what happens when a piece of food gets lodged inside one’s body, whereas strangulation is when someone applies pressure to their neck, their carotid arteries, with the intent of closing off the blood supply to the brain,” Susan B. Sorenson, a professor at the University of Pennsylvania and director of the Ortner Center on Family Violence, told Jezebel. “Choking is something that happens from the inside out; strangulation is something from the outside in.”

That clarity is important to domestic violence advocates. “Strangulation is a particularly pernicious form of intimate partner violence,” Sorenson said. Non-fatal strangulation is considered a “hallmark element of relationship violence” by experts because it is often a sign of escalation or the “intensification of relationship violence.” Some studies have also found that strangulation is linked to domestic violence-related homicide; an oft-cited study from 2008 found that “women who were the victims of completed or attempted homicide were far more likely to have a history of strangulation.” Experts are quick, however, to warn that those studies aren’t necessarily predictive, while emphasizing that strangulation is especially horrific as it can leave lasting neurological and psychological damage. In short, the act of strangulation is uniquely violent and should be viewed as such, regardless of its predictive elements.

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Non-fatal strangulation is of such singular concern that during the 2013 reauthorization of the Violence Against Women Act (VAWA), then-deputy Attorney General Sam Hirsch and former U.S. District Attorney for the District of Montana Michael W. Cotter recommended that strangulation assaults be a “separate felony offense and taken extremely seriously at sentencing.” In their statement to the United States Sentencing Commission, Hirsch and Cotter noted: “Strangulation is more common than was once realized. Recent studies have shown that 34 percent of abused pregnant women reported being ‘choked.’ In another study, 47 percent of female domestic violence victims reported being ‘choked.’”

Those numbers are reflected in the news cycle: Close to the White House, both Porter and Steve Bannon have been accused of strangulation. So has Andy Puzder, Donald Trump’s original nominee to head the Department of Labor. Bill O’Reilly, who Trump once described as a “good person,” has been accused of strangulation as well. Outside of the White House orbit finds recent allegations of strangulation against actor TJ Miller, Vice writer Michael Hafford (who penned Broadly’s “Male Feminist” column), and punk frontman Handsome Dick Manitoba, just to name a few.

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When VAWA was reauthorized, those recommendations were taken seriously: for the first time, strangulation language was added to the federal law within the category of felony assault. VAWA now has a maximum 10-year felony assault provision for anyone “attempting to strangle or suffocate” either “a spouse, intimate partner, or dating partner.” In addition to VAWA, numerous states have also made non-fatal strangulation a separate felony offense.

Despite the increased awareness of the harm of strangulation and that reflection in state and federal law, strangulation still presents a unique problem for law enforcement. As Sorenson pointed out, strangulation often leaves no immediate visible injuries. “When police arrive there’s typically no evidence right away,” Sorenson said. “If there’s bruising that occurs, it may show up later. The way our law enforcement resources are at this point in time, police don’t have the resources or opportunity to go back and check on victims a couple days later,” she added. The lack of immediate visible injuries “interferes with criminal justice approaches,” Sorenson noted, since numerous states require visible injuries “as a criterion for arrest.”

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Since strangulation is often internal and can sometimes leave no visible marks or light bruising that is hard to detect, it often doesn’t grab attention quite like a photograph of a bruised face or broken bones. Think of how the photographs of Holderness, Rob Porter’s first wife, were reproduced across the web. The black and blue ring around her eye was treated as indisputable proof of Porter’s brutality or a metaphor for the “true face” of the administration itself even as Porter himself denied the context of Holderness’s photographs. Holderness’s black eye was viewed as representative of intimate partner violence while the allegations of strangulation—unseen and unrepresented—were largely overlooked, despite the long-term effects, as well as its relationship to escalation and domestic violence-related homicide.

Strangulation, Sorenson said, is “a form of abuse that can be used repeatedly, often with impunity. Again, because it’s difficult to document the injuries.” That insistence on visible injuries, easily documented by a camera, is particularly pernicious for women of color. Even though black women are “significantly more likely” to experience strangulation, it’s often harder to document later bruising. “For women with darker skin, bruises don’t show in the same way,” Sorenson said, leaving women of color especially vulnerable to legal and cultural demands for immediate and obvious photographic evidence, rather than the slow visibility associated with strangulation. Indeed, the largest study conducted on non-fatal strangulation, the San Diego study, found that most cases lacked visible injury of strangulation: “Only 15 percent of the victims had a photograph of sufficient quality to be used in court as physical evidence of strangulation.”

Since strangulation is hard to see, it often goes undetected not just by law enforcement but by medical professionals as well. Though injuries from strangulation can be hard to document, they can be lasting and serious. In addition to neurological damage, strangulation can cause strokes, blood clots and mild to severe brain injuries. Many victims are never diagnosed or are diagnosed much later since emergency rooms are not adequately prepared to detect the early signs of strangulation. This, again, leaves the victim in a precarious position, with little legal recourse and inadequate medical care.

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Add to that the long-lasting psychological effects of strangulation. “Strangulation creates intense fear because your life is literally in someone’s hands,” Sorenson said. “I have drawn an analogy to waterboarding because I think strangulation is the domestic violence equivalent of waterboarding,” Sorenson said. “It can be used repeatedly, often without detection, and it has intense fear and reasonable fear associated with it. Repeated loss of consciousness, whether through waterboarding or being strangled can lead to brain damage.”

Sorenson stressed the psychological effects of strangulation since the act is a literal expression of an abuser’s power over a victim’s life. “Intimate partner strangulation creates an environment of intense fear—of reasonable fear—such that a woman is perhaps more afraid of leaving,” Sorenson said. She added that strangulation makes a victim keenly “aware of how she could be killed” because an abuser “has already taken her to that limit.” “When someone has taken you to that limit and then pulled back, that’s an attempted homicide,” she said.

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The allegations of strangling made against Porter, as well as Bannon, Puzder, O’Reilly, and others, are a grim reminder of its commonplace violence. Photographs of black and blue faces or bodies no doubt testify to the violent realities of intimate partner violence, but overvaluing its visual evidence over the testimony of the victim is a reminder too of the realities strangulation’s near invisibility and the danger that such narrative neglect can present to victims.

Strangulation, Sorenson said, is “not as easily dismissed or easily minimized,” by the victim. “It’s simply not forgotten,” she added.

Donald Trump and other White House officials, however, might disagree. A recent report indicates that Porter was being considered for a promotion to deputy chief of staff, with the active support of Kelly, as well as Jared Kushner and Ivanka Trump, despite the White House’s knowledge of the allegations leveled against Porter. Days after Porter tendered his resignation, Trump came to his defense, as he did with O’Reilly, Puzder, and Bannon. “Peoples lives are being shattered and destroyed by a mere allegation,” the president tweeted on Saturday, a vague reference perhaps to all of the “good men,” he has relentlessly defended—despite their histories of strangulation and other intimate partner violence.