CHAPTER 9: IVP

IVP incidence

1. Average, 20 persons per minute are victims of rape, physical violence, or stalking by an intimate partner in the US 2. IPV causes more serious injuries and deaths than automobile accidents, rapes, and muggings combined 3. Medical community's efforts to address IPV have often neglected members of the LGBT population.

health effects of IVP

1. In addition to injuries, exposure to IPV increased risk for: a. Chronic health issues, Asthma, Cancer, Hypertension, Depression, Substance Abuse, Poor reproductive health outcomes, HIV 2. ASSOCIATED SYMPTOMS a. Headache, Dizziness, Chest pain, Palpitations, Back pain, Nausea and indigestion, Stomach pain, Diarrhea and constipation, Menstrual/pelvic pain, Dyspareunia, Insomnia, Depression, Anxiety, PTSD and suicidal thoughts

risk for abuse-related murders

1. Increased frequency or severity of abuse 2. Presence of firearms 3. Sexual abuse 4. Substance abuse 5. Precipitated by arguments and conflicts 6. Generally violent behavior outside of the home 7. Control issues (e.g., daily chores, friends, job, money) 8. Physical abuse during pregnancy 9. Suicide threats or attempts (victim or abuser) 10. Child abuse

nursing management for rape victims

1. A SANE is a registered nurse specially trained to conduct sexual assault evidentiary examinations for rape victims a. Also provide access to crisis intervention, STI testing, and emergency contraception 2. Exposure therapy has been used to help victims confront their trauma-related memories, feelings, and stimuli that evoke fear and anxiety 3. Nursing care of the rape survivor should focus on providing supportive care, collecting and documenting evidence, assessing for STIs, preventing pregnancy, and assessing for PTSD 4. Follow-up care should include counseling, medical treatment, and crisis intervention 5. Early intervention has been correlated with speedy recovery

violence against pregnant women

1. At higher risk for violence during pregnancy 2. Prior abuse usually indicates abuse during pregnancy 3. IPV appears to last longer if women have children, and this also seems to be the case even after the partnership has come to an end 4. Physical violence may involve injuries to the head, face, neck, thorax, breasts, and abdomen. 5. Depression and PTSD; poor quality of life; increased distress, fearfulness, anxiousness, and stressfulness; and increased use of tobacco, alcohol, and/or illicit drugs 6. Frequently the fear of harm to her unborn child will motivate a woman to escape an abusive relationship. 7. Signs of abuse can emerge during pregnancy and may include poor attendance at prenatal visits, unrealistic fears, weight fluctuations, difficulty with pelvic examinations, and nonadherence to treatment.

abusers

1. Often feel insecure, powerless, and helpless; feelings that are not in line with the macho image they would like to project. 2. Expresses inadequacy through violence 3. Childlike aggression or antisocial behaviors. 4. Fail to accept responsibility or blame others for their own problems. 5. History of substance abuse problems, trouble with the justice system, few close relationships, being sensitive to criticism, having a tendency to hold grudges, involved in power struggles, emotionally dysregulated, lacking in insight, prone to feeling misunderstood, mistreated, or victimized, mental illness, arrests, troubled relationships, obsessive jealousy, controlling behaviors, generally violent behavior, erratic employment history, and financial problems

safety plan for leaving an abusive relationship

1. Driver's license or photo ID 2. Social Security number or green card/work permit 3. Birth certificates for you and your children 4. Phone numbers for social services or women's shelter 5. The deed or lease to your home or apartment 6. Any court papers or orders 7. A change of clothing for you and your children 8. Pay stubs, checkbook, credit cards, and cash 9. Health insurance cards 10. If you need to leave a domestic violence situation immediately, turn to authorities for assistance in gathering this material. 11. Develop a "game plan" for leaving and rehearse it. 12. Don't use phone cards—they leave a trail to follow.

Violence Against Older Women

1. Elder mistreatment is intentional actions that cause harm or create a serious risk of harm to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder 2. Female elders are abused at a higher rate than males and that the older one is, the more likely one is to be abused 3. Types of abused usually experienced: physical abuse, neglect, emotional abuse, sexual abuse, and financial/exploitation abuse 4. Physical and emotional sequelae of IPV may be more subtle and may include depression, insomnia, chronic pain, difficulty trusting others, low self-esteem, thoughts of suicide, substance abuse, anger issues, atypical chest pain, or other kinds of somatic symptoms 5. Older women usually have endured long-term abuse, have developed unhealthy strategies to cope, and shoulder blame from their adult children, yet have developed empowerment from within to be able to cope with the abuse 6. Nurses should determine what the client has done to attempt to resolve the abuse and the effectiveness of those strategies.

IVP background

1. IPV was often tolerated and even socially acceptable.

sexual abuse

1. Peak ages of abuse 8-12yrs 2. When a woman is forced to have sexual contact of any kind (vaginal, oral, or anal) without her consent. 3. Females are more likely to be sexually abused by father, brother, family member, neighbor, boyfriend, husband, partner, or ex-partner than by a stranger or anonymous assailant. 4. Marriage does not constitute a tacit agreement to inflict one's demands on the other without permission 5. Childhood sexual abuse is any type of sexual exploitation that involves a child younger than 18 years old a. Disrobing, nudity, masturbation, fondling, digital penetration, forced performance of sexual acts on the perpetrator, and intercourse 6. Girls that are sexually abused in childhood are at risk for repeat abuse. 7. Early abuse lowers their self-esteem and their ability to protect themselves and set firm boundaries 8. Influences the way victims form relationships, deal with adversity, cope with daily problems, relate to their children and peers, protect their health, and live. 9. Interventions for sexually abused children or women should include referral for mental health counseling. 10. Medical consequences of sexual abuse require the prophylaxis and treatment of STIs, emergency contraception, and treatment of any injuries that resulted from the abuse 11. Psychosocial aspects of sexual abuse must also be addressed because appropriate therapeutic follow-up is essential to the victim's future emotional well-being.

rape

1. Penile penetration of the vagina, mouth, or rectum of the female or male without consent. 2. Expression of violence, not a sexual act. 3. Not an act of lust or an overzealous release of passion: it is a violent, aggressive assault on the victim's body and integrity 4. Involve the motives of anger, power, eroticized cruelty, and opportunistic mating 5. Statutory rape is sexual activity between an adult and a person under the age of 18 and is considered to have occurred even if the underage person was willing 6. 4 Phases of Rape Recovery

victims

1. Rarely describe themselves as abused 2. Terrified and feels trapped, helpless, and alone 3. Reacts to any expression of anger or threat by avoidance and withdrawal behavior. 4. May have poor self-esteem, poor health, PTSD, depression, insomnia, low education achievement, or a history of suicide attempts, injury, or drug and alcohol abuse

characteristics of intimate partner violence risk factors

1. Risk factors for IPV in men can be divided into four different categories: individual factors, relationship factors, community factors, and societal factors.

incest

1. Sexual activity between persons so closely related that marriage between them is legally or culturally prohibited 2. Crime but also a symptom of acute and irreversible family dysfunction. 3. Women with a history of incest exhibit a clinical syndrome that includes low self-esteem, difficulty with intimate relationships, sexual dysfunction, flashbacks and nightmares, repeated victimization, as well as suicidality, depressive symptomatology, eating disorders, and substance abuse 4. Children often do not report or ask for help. 5. Recovery process begins with admission of abuse and the recognition that help and services are needed. 6. Resources for incest victims include books, self-help groups, workshops, therapy programs, and possibly legal remedies. 7. Incest can have serious long-term effects on its victims, which may include eating disorders, sexual problems in adult life, difficulty in interpersonal relationships, anxiety, PTSD, intense guilt and shame, low self-esteem, depression, and self-destructive behavior

acquaintance rape

1. Someone is forced to have sex by a person he or she knows 2. Date rape, an assault that occurs within a dating relationship or marriage without consent of one of the participants, is a form of acquaintance rape 3. Survivors of acquaintance rape report similar levels of depression, anxiety, complications in subsequent relationships, and difficulty attaining pre-rape levels of sexual satisfaction to those reported by survivors of stranger rape 4. Victims often blame themselves

types of abuse

1. emotional abuse 2. physical abuse 3. finanial abuse 4. sexual abuse

acquaintance rape cont

1. often experience PTSD 2. symptoms of PTSD are divided into 3 groups a. Intrusion (reexperiencing the trauma, including nightmares, flashbacks, recurrent thoughts) b. Avoidance (avoiding trauma-related stimuli, social withdrawal, emotional numbing) c. Hyperarousal (increased emotional arousal, exaggerated startle response, irritability)

primary prevention

i. Aimed at breaking the abuse cycle through community educational initiatives by nurses, physicians, law enforcement, teachers, and clergy.

ask direct or indirect questions about abuse

i. Ask difficult questions in an empathetic and nonthreatening manner and remain nonjudgmental in all responses and interactions. ii. Direct and indirect questions produce the same result so chose a way that you the nurse feel comfortable asking

characteristics of intimate partner violence generation-generation continuum of violence

2. Generation-to-Generation Continuum of Violence a. Violence is a learned behavior b. Children who witness one parent abuse another are more likely to become delinquents or batterers themselves because they see abuse as an integral part of a close relationship. c. Violence in childhood is linked to child's perspective of family as a hostile environment and of violence against women as a corrective measure, and insults, swearing, and humiliation by their partner is acceptable d. Children who witness IPV are at risk for developing psychiatric disorders, PTSD, developmental problems, school failure, violence against others, and low self-esteem e. Women who were physically or sexually abused as children have an increased risk of victimization and fear of crime, poor general health, and in addition experience adverse mental health conditions such as depression, anxiety, and low self-esteem as adults f. If parent is abused, children usually will be too g. Cycle continues into another generation through learned responses and violent acting out. h. Most children deprived of their basic physical, psychological, and spiritual needs do not develop healthy personalities. i. They grow up with feelings of fear, behavioral problems, substance abuse, relationship difficulties, inadequacy, anxiety, anger, hostility, guilt, and rage i. Lack coping skills, blame others, demonstrate poor impulse control, have early delinquent behavior, and generally struggle with authority

rape victims preventing pregnancy

a. Pregnancy can be prevented by using an emergency contraceptive pill, sometimes called postcoital contraception. Emergency contraceptive pills involve high doses of the same oral contraceptives that millions of women take every day. b. Emergency contraception works by preventing ovulation, fertilization, or implantation DOES NOT disrupt pregnancy c. Emergency contraception is most effective if it is taken within 12 hours of the rape; it becomes less effective with every 12 hours of delay thereafter.

financial abuse

a. Preventing the woman from getting a job b. Sabotaging a current job c. Controlling how all money is spent d. Failing to contribute financially

female genital cutting

a. Procedure involving any injury of the external female genitalia for cultural or nontherapeutic reason b. Human rights violation

emotional abuse

a. Promising, swearing, or threatening to hit the victim b. Forcing the victim to perform degrading or humiliating acts c. Threatening to harm children, pets, or close friends d. Humiliating the woman by name-calling and insults e. Threatening to leave her and the children f. Isolation from family and friends g. Destroying valued possessions h. Controlling the victim's every move

tertiary prevention

Activities are geared toward helping severely abused women and children recover and become productive members of society and rehabilitating abusers to stop the cycle of violence. These activities are typically long term and expensive.

nursing management of intimate partner violence assessment

a. Routine screening for IPV is the 1st way to detect abuse b. Build rapport by listening, showing an interest in the concerns of the woman, and creating an atmosphere of openness. c. Communicate support nonjudgmentally and say "no one deserves to be abused"

rape victims collecting and documenting evidence

Bring all clothing, especially undergarments, worn at the time of the assault to the medical facility. The victim should not shower or bathe before presenting for care

rape victims supportive care

a. Take the woman to a secure, isolated area away from family, friends, and other clients and staff so she can be open and honest when asked about the assault. b. Provide a change of clothes, access to a shower and toiletries, and a private waiting area for family and friends.

nursing daignosis

a. Deficient knowledge related to understanding the cycle of violence and availability of resources b. Anxiety related to threat to self-concept, situational crisis of abuse c. Situational low self-esteem related to negative family interactions d. Powerlessness related to lifestyle of helplessness e. Compromised individual and family coping related to abusive patterns

nursing interventions

a. Goal is to let her gain control of her life

female genital cutting performed to

Female cutting is performed to decrease a woman's sexual desires and to ensure her chastity until marriage and receipt of a dowry from the prospective groom i. Frequently performed without anesthesia under nonsterile condition

date rape drugs

a. Most common club drug/ date rape drug is rohypnol (also known as "roofies," "forget pills," "mind erasers," or the "drop drug"). It comes in the form of a liquid or pill that quickly dissolves in liquid with no odor, taste, or color. i. Memory loss for up to 8hr, effective in 30 min b. Gamma hydroxybutyrate (GHB; called "liquid ecstasy" or "easy lay") produces euphoria, an out-of body high, sleepiness, increased sex drive, and memory loss. GHB takes effects in about 15 minutes and can last 3 to 4 hours c. Ketamine (known as "Special K," "vitamin K," or "super acid"), and acts on the central nervous system. very quickly to separate perception and sensation. Combining ketamine with other drugs can be fatal.

nursing management of intimate partner violence screening

Nurses need to know how to screen for violence how to respond in a helpful way, to be sincere, nonjudgmental, and legally adequate

rape victims assessing for sexually transmitted infections

a. Pelvic examination will be done to collect vaginal secretions to rule out any STIs

rape victims assessing for PTSD

a. At the first opportunity, the woman should be encouraged to talk about the traumatic experience. b. To diminish symptoms of PTSD, survivors must work on two fronts: coming to terms with the past and alleviating stress in the present c. Do upsetting thoughts and nightmares of the trauma bother you? d. Do you feel as though you are actually reliving the trauma? e. Does it upset you to be exposed to anything that reminds you of that event? f. Do you find yourself trying to avoid thinking about the trauma? g. Do you stay away from situations that remind you of the event? h. Do you have trouble recalling exactly what happened? i. Do you feel numb emotionally? j. Are you having trouble sleeping? k. Have you felt irritable or experienced outbursts of anger? l. Do you have heart palpitations and sweating? m. Do you have muscle aches and pains all over

cycle of violence

a. Cycle of violence comprises three distinct phases: the tension-building phase, the acute battering phase, and the honeymoon phase b. Tension-building arguments progresses to violence and settles into a making-up or calm period. c. Honeymoon phase gradually shortens and eventually disappears altogether.

traficking

a. The recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force, of abduction, of fraud, or deception to achieve the consent of a person having control over another person, for the purpose of exploitation b. Women and children are the primary victims of human trafficking, many in the sex trade as described above and others through forced-labor domestic servitude. c. Victims are primarily women and children who lack education, employment, and economic opportunities in their own countries. d. Traffickers promise victims employment as nannies, maids, dancers, factory workers, sales clerks, or models in the United States. e. Traffickers transport the victims from their counties to unfamiliar destinations away from their support systems. f. Once they are here, traffickers coerce them, using rape, torture, starvation, imprisonment, threats, or physical force, into prostitution, pornography, the sex trade, forced labor, or involuntary servitude. g. Victims are exposed to serious and numerous health risks such as rape; physical injury such as cigarette burns, fractures, bruises; torture; HIV/AIDS; STIs; cervical cancer; violence; hazardous work environments; poor nutrition; and drug and alcohol addiction

women assaulted during pregnancy are at risk for

a. injuries to themselves and the fetus b. Depression c. Panic disorder d. Fetal and maternal deaths e. Chronic anxiety f. Miscarriage g. Stillbirth h. Poor nutrition i. Insomnia j. Placental abruption k. Uterine rupture l. Excessive weight gain or loss m. Smoking and substance abuse n. Delayed or no prenatal care o. Preterm labor p. Higher rate of surgical births q. Chorioamnionitis r. Vaginitis s. Sexually transmitted infections (STIs) t. Urinary tract infections u. Premature and low-birth-weight infants

female genital cutting types

c. Surgical removal of a portion or portions of the genitalia of female infants, girls, and women, including the clitoris (type I), clitoris and labia minora (type II), and clitoris, labia minora, labia majora, and then suturing of the remaining tissue, known as fibulation, to leave only a small opening for urination, menstruation, intercourse, and childbirth (type III) d. Type IV, which encompasses all other mutilations of the female genital area such as pricking, piercing, cutting, cauterizing, and scraping of the vaginal tissue, incisions to the clitoris and vagina, and burning, scarring, or cauterizing of tissue with the aim of tightening or narrowing the vagina

genital cutting cont

e. Countries where this is practiced include 30 African countries and parts of the Middle East and Asia. f. May be interwoven into the culture, it is not mandated by any religion g. Some cultures, it is associated with feminine beauty and often signifies a rite of passage from childhood to adulthood.

physiologic effects from genital cutting

eating disorders, insomnia, depression, PTSD, and negative effects on the women's self-esteem and identity

nursing interventions cont

g. Offer step-by-step explanations of procedures. h. Provide education about violence i. Allow her to take control Over her healthcare decisions

nursing interventions listening

i. "I hear and understand what you are saying." Being listened to can be an empowering experience for a woman who has been abused.

nursing interventions validating the decision to disclose

i. "It must have been difficult for you to talk about this today."

nursing interventions communication belief

i. "That must have been very frightening for you."

nursing interventions emphasizing the unacceptability of this violence

i. "You don't deserve to be treated this way."

document and report your findings

i. Accurate documentation of History of abuse is important because it may be evidence in her court case ii. Must include details about the frequency and severity of abuse; the location, extent, and outcome of injuries; and any treatments or interventions iii. Use direct quotes and be very specific iv. Describe any visible injuries and use a body map to show where the injuries are. v. Obtain photos or document her refusal if she declines vi. Laws in many states require health care providers to alert the police to any injuries that involve knives, firearms, or other deadly weapons or that present life-threatening emergencies. 1. Nurses can explain to her that they are required by law to report it

isolate client immediately from family

i. Ask direct/indirect questions about abuse like you would ask any other question. ii. Assessment can happen anywhere that is private: elevator, bathroom, X-ray room, just make sure she's alone iii. Educate the woman about the connection between the violence and her symptoms. iv. Help the woman acknowledge what has happened to her and begin to deal with the situation. v. Offer her referrals so she can get the help that will allow her to begin to heal.

nursing interventions for human traficking

i. Building trust is the number-one priority ii. Take the time to listen and develop rapport iii. Screen in a private place to ensure confidentiality and safety iv. Reassure the potential victim v. One-on-one interactions are ideal vi. Specifically ask about the client's safety vii. Offer reworded stories viii. Stay calm and on an even keel ix. Understand the risk these victims are taking by disclosing their plight x. Always document your suspicion in your notes, at the very least xi. Call the human trafficking hotline for guidance: 1-866-US-TIPLINE xii. If you suspect a trafficking situation, notify local law enforcement and a regional social service organization that has experience in dealing with trafficking victims

assess immediate safety

i. Does she feel safe going home after her meeting with you? ii. Does she need an immediate place of safety for herself or her children? iii. Does she have a plan of escape if she becomes at risk for her safety? iv. Does she need to consider an alternative exit from this building? v. Who are the people she could contact for help or support?

secondary prevention

i. Focuses on screening high-risk individuals and dealing with victims and abusers in early stages, with the goal of preventing progression of abuse.

IVP

i. IPV is actual or threatened physical or sexual violence or psychological/emotional abuse. ii. Violence often accompanied by psychological abuse and in one third to over one half of cases by sexual abuse iii. Domestic abuse, spouse abuse, domestic violence, gender-based violence, battering, and rape. iv. Important for nurses to be able to identify abuse and aid the victim.

sexual violence

i. Includes IPV, human trafficking, incest, FGC, forced prostitution, bondage, exploitation, neglect, infanticide, and sexual assault ii. National Center for Prevention and Control of Sexual Assault estimates that two thirds of sexual assaults will not be reported iii. Women can experience psychological, physical, and cognitive symptoms that affect them daily. iv. Include chronic pelvic pain, headaches, backache, STIs, pregnancy, anxiety, denial, fear, withdrawal, sleep disturbances, guilt, nervousness, phobias, substance abuse, depression, sexual dysfunction, and PTSD. Many contemplate suicide v. Characteristics of Assailant - No clear profile 1. Such men become angry and experience feelings of powerlessness. 2. They become jealous easily; do not view women as equals; frequently are hot tempered; have a need to be reassured of their manhood; and do not handle stress in their lives well. 3. They commit a sexual assault as an expression of power and control

screening for abuse during everyday health care visit

i. Injuries— 1. Bruises on their chest and abdomen, scars from blunt trauma, minor lacerations, or weapon wounds on the face, head, and neck ii. Injury sequelae— 1. Headaches, hearing loss from ruptured ear drums, joint pain, sinus infections, teeth marks, clumps of hair missing, dental trauma, pelvic pain, and breast or genital injuries iii. Reported history of injury that is not consistent with the actual presenting problem iv. Mental health problems— 1. Depression, anxiety, substance abuse, eating disorders, suicidal ideation or suicide attempts, anger toward health care provider, and PTSD v. Frequent tranquilizer or sedative use vi. Delay in seeking medical attention and patterns of repeated injury vii. Bruises to the upper arm, neck and face, abdomen, or breasts viii. Comments about emotional or physical abuse of "a friend" ix. STIs or pelvic inflammatory disease x. Appears nervous, ashamed, or evasive when asked questions xi. Frequent health care visits for chronic, stress-related disorders such as chest pain, headaches, back or pelvic pain, insomnia, injuries, anxiety, and gastrointestinal disturbances. xii. Partner's behavior at the health care visit: appears overly solicitous or overprotective, is unwilling to leave her alone with the health care provider, answers questions for her, and attempts to control the situation

educate the woman about community services

i. Might include psychological counseling, legal advice, social services, crisis services, support groups, hotlines, housing, vocational training, and other community-based referrals. ii. Routine IVP screening, counseling, and referrals in all health care agencies iii. Give her info about shelters or services even if she initially rejects it

genital cutting background

i. NOT rooted in religion ii. Some consider it a rite of passage into womanhood; others use it as a means of preserving virginity until marriage. iii. No health benefits

nursing management for genital cutting

i. Nurses must keep in mind that FGC is considered normal in many cultures and to not have it done would be unthinkable ii. Speak clearly and slowly, using simple, accurate terms. iii. Use the term or name for this practice that the recipient uses, not "female genital cutting." iv. Use pictures and diagrams to help the woman understand what you are saying. v. Be patient in allowing the client to answer questions. vi. Include men in any education, as they are influential in this practice. vii. Repeat back your understanding of the client's statements. viii. Always look and talk directly to the client, not the interpreter. ix. Place no judgment on the cultural practice. x. Maintain respect for older women who have experienced FGC. xi. Encourage the client to express herself freely. xii. Maintain strict confidentiality. xiii. Provide culturally attuned care to all women xiv. FGC is a form of violence against women, and it is only through education and empowerment of women that real changes in this practice can be made

safety plan

i. Offer choices, but the choice to leave is the victims. ii. Frequently, the final attempt to leave may result in the death of the victim. iii. Safety Plan for Leaving an Abusive Relationship

phase 3:

i. Period of calm, loving, and contrite behavior on the part of the batterer. He may be genuinely sorry for the pain he caused his partner ii. Victim wants to believe that the partner can change. Abuser thinks he could never hurt their victim iii. Victim feels responsible for her partner's well-being

provide emotional support

i. Teaching coping strategies to manage her stress ii. Assisting with activities of daily living to improve her lifestyle iii. Allowing her to make as many decisions as she can iv. Educating her about the symptoms of PTSD and their basis v. Teaching problem-solving skills vi. Encouraging social activities to connect with other people vii. Listening to and clarifying her reactions to the traumatic event viii. Discussing shock, disbelief, anger, depression, and acceptance ix. Abuse is never OK. She didn't ask for it and she doesn't deserve it x. She is not alone and help is available xi. Abuse is a crime and she is a victim xii. Alcohol, drugs, money problems, depression, or jealousy does not cause violence, but these things can give the abuser an excuse for losing control and abusing her xiii. The actions of the abuser are not her fault xiv. Her history of abuse is believed xv. Making a decision to leave an abusive relationship can be very hard and takes time

phase 2: acute battering-explosion of violence

i. Victim may be assaulted or murdered. ii. Often deny their injuries and refuse to seek treatment

phase 1: tension building-usually the longest cycle

i. tension escalates between the couple ii. Excessive drinking, jealousy, or other factors might lead to name-calling, hostility, and friction. iii. In her mind, if she does her job well, he remains calm. But if she fails, the resulting violence is her fault.

genital cutting complications

infertility, dysmenorrhea, dyspareunia, sexual dysfunction, infection, hemorrhage after the procedure, vaginal stenosis, chronic vaginitis, pelvic inflammatory disease, chronic urinary tract infections, incontinence, genital fistulas, recurrent abscesses, transmission of HIV and hepatitis during the procedure, severe pain and shock after the procedure, difficulty walking or using stairs due to severe scarring, urinary retention, inability to experience orgasm, and difficulty in giving birth. k. Long term complications: chronic pain, dyspareunia, and difficult childbirth. l. Most common long-term complication is the formation of inclusion clitoral dermoid cysts and labial fusion. i. Become large as a grapefruit and can lead to difficulty in walking, sitting and can cause psychological distress from the deformity

teaching problem-solving skills

vi. Encouraging social activities to connect with other people vii. Listening to and clarifying her reactions to the traumatic event viii. Discussing shock, disbelief, anger, depression, and acceptance ix. Abuse is never OK. She didn't ask for it and she doesn't deserve it x. She is not alone and help is available xi. Abuse is a crime and she is a victim xii. Alcohol, drugs, money problems, depression, or jealousy does not cause violence, but these things can give the abuser an excuse for losing control and abusing her xiii. The actions of the abuser are not her fault xiv. Her history of abuse is believed xv. Making a decision to leave an abusive relationship can be very hard and takes time