Talia Meer

Behind the screens: Domestic violence and health care practices

abstract Domestic violence (DV) is one of the most pervasive forms of violence in South Africa with numerous physical and psychological consequences that have severe and enduring impacts on health. This takes a significant toll on women, their families and the health care system. Local and international literature suggests that DV is one of the most common reasons for women to present at health care facilities, placing health care practitioners in a unique position to identify abuse and intervene. As widespread as it is, DV is not a specifically prioritised public health concern and thus suffers from vastly inadequate resource allocation. The Domestic Violence Act, No 116 of 1998, was the first and only South African legislative attempt to recognise DV victims’ rights to seek immediate medical assistance. It did not, however, impose any positive legal duties on health care practitioners to inquire about, screen for or holistically treat DV-related injuries and other health-related consequences of DV or make referrals. The Act only implies that health care practitioners have a duty to attend to DV cases. International codes delineate duties for health care practitioners in providing care for women in abusive relationships, and South Africa has detailed medico-legal protocols for the examination and treatment of survivors of sexual offences. It is therefore curious that a similar treatment protocol does not exist for DV. This Article reviews the literature on the health consequences of DV and the need for screening, and recounts the historical attempts of civil society in South Africa to impose legal duties on the state to assist DV victims who present to health care facilities. We argue that it is time that Parliament review the provisions of the Domestic Violence Act to include legal duties on health care practitioners to properly address the health consequences of DV.

Invisible intersections: Understanding the complex stigmatisation of women with intellectual disabilities in their vulnerability to gender-based violence

abstract Of the range of disabilities, intellectual disabilities are often the most complex and least understood. The effects of the disability and related negative social attitudes and perceptions combine with the pernicious effects of sexism and misogyny, so that women with these kinds of disabilities are frequently and disproportionally subject to gender-based violence (GBV). This article explores the stigmatisation that renders women with intellectual disabilities more vulnerable to victimisation from the perspective of service providers in the disability and GBV sectors. The data are taken from a larger study on GBV and access to justice for women with intellectual and psychosocial disabilities undertaken in the Western Cape, Gauteng, and KwaZulu-Natal, wherein we interviewed 58 service providers at disability and GBV organisations. In the process, service provider narratives indicated that the experiences of women with intellectual disabilities, including their vulnerability to and experiences of violence, are mediated by multiple complex social perceptions and myths. According to our findings these include the general view that people with disabilities are less valuable, cultural myths and superstitions about disability, fear and shame associated with ‘disabled’ sexuality, beliefs about the lack of credibility of persons with intellectual disabilities, and the tendency of persons with disabilities to internalise negative views about themselves. These myths and perceptions are not mutually exclusive, but combine and interact in complex and compound ways, often rendering the victimisation of women with intellectual disabilities invisible, or intractable. This article aims to highlight the relationship between intellectual disabilities and prevailing social attitudes as a central concern in the prevention of and responses to violence against women with intellectual disabilities.

“They treat us like we’re not there”: Queer bodies and the social production of healthcare spaces

Abstract There is significant literature demonstrating the interpenetrability of identity and space, yet there is almost no work that explores the co‐production of queer identities and healthcare spaces. We use Lefebvre’s triad of (social) space to explore how the social spaces of South African healthcare facilities shape and are shaped by queer service‐users, drawing on data from interviews and focus group discussions with 29 queer service‐users and 14 representatives of organisations. Findings reveal that healthcare spaces are produced by the spatial ordering of health policy inattentive to queer health needs; the enduring symbolic representations of queerness as pathological or ‘un‐African’; and various identity assertions and practices of individuals, including queer service‐users and healthcare providers. As a result, healthcare spaces are overwhelmingly heteronormative, although queer service‐users’ subversive practices suggest alternative spatial configurations. However, such resistance relies on individual empowered action and risks disciplining responses. Wider efforts are needed to transform the material and ideological space of healthcare facilities through law and policy reform and continuing professional training for healthcare providers.

Considering intersectionality in Africa

The concept of intersectionality, first conceived by Kimberle Crenshaw (1989), has widely been acknowledged as one of the most significant contributions of feminist scholarship. Broadly speaking, intersectionality posits that different social identities like race, gender, class and sexuality intersect and inform each other in what Patricia Hill Collins (1993) calls “interlocking systems of oppression”. Consequently, it is the intersection of multiple identities that influences individual worldviews and lifechances differently than would any single form of social stratification.

Legal duties, professional obligations or notional guidelines? Screening, treatment and referral of domestic violence cases in primary health care settings in South Africa

Background Since 2013, approximately 4400 women have been murdered by their partners in South Africa. This is five times higher than the per capita global average. Domestic violence is known to be cyclical, endemic and frequently involves multiple victims. It also becomes progressively more dangerous over time and may lead to fatalities. In 2012, the Health Professions Council of South Africa released a domestic violence protocol for emergency service providers. This protocol, or screening guidelines, includes assessing future risk to domestic violence, providing physical and psychosocial care, documentation of evidence of abuse and informing patients of their rights and the services available to them. The extent to which these guidelines have been circulated and implemented, particularly by general health care practitioners (HCPs), is unknown. Aim We review international treaties to which South Africa is a signatory, as well as national legislation and policies that reinforce the right to care for victims of domestic violence, to delineate the implication of these laws and policies for HCPs. Method We reviewed literature and analysed national and international legislation and policies. Results The ‘norms’ contained in existing guidelines and currently practiced in an ad hoc manner are not only compatible with existing statutory duties of HCPs but are in fact a natural extension of them. Conclusion Proactive interventions such as the use of guidelines for working with victims of domestic violence enable suspected cases of domestic violence to be systematically identified, appropriately managed, properly referred, and should be adopted by all South African HCPs.

“The care is the best you can give at the time”: Health care professionals’ experiences in providing gender affirming care in South Africa

Background While the provision of gender affirming care for transgender people in South Africa is considered legal, ethical, and medically sound, and is—theoretically—available in both the South African private and public health sectors, access remains severely limited and unequal within the country. As there are no national policies or guidelines, little is known about how individual health care professionals providing gender affirming care make clinical decisions about eligibility and treatment options. Method Based on an initial policy review and service mapping, this study employed semi-structured interviews with a snowball sample of twelve health care providers, representing most providers currently providing gender affirming care in South Africa. Data were analysed thematically using NVivo, and are reported following COREQ guidelines. Results Our findings suggest that, whilst a small minority of health care providers offer gender affirming care, this is almost exclusively on their own initiative and is usually unsupported by wider structures and institutions. The ad hoc, discretionary nature of services means that access to care is dependent on whether a transgender person is fortunate enough to access a sympathetic and knowledgeable health care provider. Conclusion Accordingly, national, state-sanctioned guidelines for gender affirming care are necessary to increase access, homogenise quality of care, and contribute to equitable provision of gender affirming care in the public and private health systems.

The no-go zone: a qualitative study of access to sexual and reproductive health services for sexual and gender minority adolescents in Southern Africa

BackgroundAdolescents have significant sexual and reproductive health needs. However, complex legal frameworks, and social attitudes about adolescent sexuality, including the values of healthcare providers, govern adolescent access to sexual and reproductive health services. These laws and social attitudes are often antipathetic to sexual and gender minorities. Existing literature assumes that adolescents identify as heterosexual, and exclusively engage in (heteronormative) sexual activity with partners of the opposite sex/gender, so little is known about if and how the needs of sexual and gender minority adolescents are met.MethodsIn this article, we have analysed data from fifty in-depth qualitative interviews with representatives of organisations working with adolescents, sexual and gender minorities, and/or sexual and reproductive health and rights in Malawi, Mozambique, Namibia, Zambia and Zimbabwe.ResultsSexual and gender minority adolescents in these countries experience double-marginalisation in pursuit of sexual and reproductive health services: as adolescents, they experience barriers to accessing LGBT organisations, who fear being painted as “homosexuality recruiters,” whilst they are simultaneously excluded from heteronormative adolescent sexual and reproductive health services. Such barriers to services are equally attributable to the real and perceived criminalisation of consensual sexual behaviours between partners of the same sex/gender, regardless of their age.Discussion/ conclusionThe combination of laws which criminalise consensual same sex/gender activity and the social stigma towards sexual and gender minorities work to negate legal sexual and reproductive health services that may be provided. This is further compounded by age-related stigma regarding sexual activity amongst adolescents, effectively leaving sexual and gender minority adolescents without access to necessary information about their sexuality and sexual and reproductive health, and sexual and reproductive health services.AbstraitContexteLes adolescents ont des besoins importants en matière de santé sexuelle et reproductive. Cependant, des cadres juridiques complexes et des attitudes sociales concernant la sexualité des adolescents, y compris les valeurs des prestataires de soins, régissent l’accès des adolescents à ces services. Ces lois et attitudes sociales sont souvent antipathiques aux minorités sexuelles et de genre. La littérature existante présuppose que les adolescents s’identifient comme hétérosexuels et se livrent exclusivement à des activités sexuelles (hétéronormatives) avec des partenaires du sexe/ genre opposé. Nous ne savons que très peu si et comment les besoins des adolescents appartenant à une minorité sexuelle ou de genre sont satisfaits.MéthodesDans cet article, nous avons analysé cinquante entretiens qualitatifs approfondis avec des représentants d’organisations travaillant avec des adolescents, des minorités sexuelles et de genre et / ou des droits et santé sexuels et reproductifs au Malawi, au Mozambique, en Namibie, en Zambie et au Zimbabwe.RésultatsDans ces pays, les adolescents appartenant à une minorité sexuelle et/ ou de genre connaissent une double marginalisation en matière d’accès aux services de santé sexuelle et reproductive: en tant qu’adolescents, ils rencontrent des obstacles pour accéder aux organisations LGBT, qui craignent d’être qualifiés de «recruteurs d’homosexualité»; alors qu’ils n’ont déjà pas accès aux services hétéronormatifs de santé sexuelle et reproductive pour adolescents. De tels obstacles aux services sont également attribuables à la criminalisation réelle et perçue des comportements sexuels consensuels entre partenaires de même sexe / genre, quel que soit leur âge.Discussion / conclusionLa combinaison de lois criminalisant l’activité consensuelle de même sexe / genre et la stigmatisation sociale envers les minorités sexuelles et de genre fait que les services légaux de santé sexuelle et reproductive pouvant être fournis ne sont pas accessibles. Cette situation est. encore aggravée par la stigmatisation liée à l’âge chez les adolescents, laissant ainsi les adolescents des minorités sexuelles et de genre sans accès aux informations nécessaires sur leur sexualité et leur santé sexuelle et reproductive, ainsi que sur les services de santé sexuelle et reproductive.AbstratoContextoOs adolescentes têm altas necessidades de saúde sexual e reprodutiva. No entanto, quadros jurídicos complexos e atitudes sociais sobre a sexualidade dos adolescentes, incluindo os valores dos cuidadores, governam o acesso dos adolescentes a esses serviços. Essas leis e atitudes sociais são muitas vezes hostis às minorias sexuais e de gênero. A literatura existente pressupõe que os adolescentes se identificam como heterossexuais e se envolvem exclusivamente na atividade sexual (heteronormativa) com parceiros do sexo / gênero opostos. Sabemos muito pouco sobre se e como as necessidades dos adolescentes pertencentes a uma minoria sexual ou de gênero estão satisfeitas.MétodosNeste artigo, analisamos cinquenta entrevistas qualitativas em profundidade com representantes de organizações que trabalham com adolescentes, minorias sexuais e de gênero e / ou direitos e saúde sexual e reprodutiva no Malawi, Moçambique, Namíbia, Zâmbia e Zimbábue.ResultadosNesses países, os adolescentes pertencentes a uma minoridade sexual e / ou de gênero experimentam uma dupla marginalização no acesso a serviços de saúde sexual e reprodutiva: como adolescentes, enfrentam obstáculos ao acesso a organizações LGBT que temem ser chamados de “recrutadores homossexuais”; enquanto eles ainda não têm acesso a serviços de saúde sexual e reprodutiva heteronormativos para adolescentes. Tais barreiras aos serviços também são atribuíveis à criminalização real e percebida do comportamento sexual consensual entre parceiros do mesmo sexo/ gênero, independentemente da idade.Discussão / ConclusãoA combinação de leis que criminalizam a atividade consensual do mesmo sexo / gênero e estigma social em relação a minorias sexuais e de gênero significa que os serviços para saúde sexual e reprodutiva que podem ser fornecidos legais não são acessíveis. Esta situação é ainda agravada pelo estigma relacionado com a idade entre os adolescentes, deixando os adolescentes de minorias sexuais e de gênero sem acesso à informação necessária sobre sua sexualidade e sua saúde sexual e reprodutiva, bem como sobre os serviços de saúde sexual e reprodutivo.

participation in practice: a case study of a collaborative project on sexual offences in South Africa

abstractIn this article we critically reflect on ‘feminist research methods’ and ‘methodology’, from the perspective of a feminist research unit at a South African university, that explicitly aims to improve gender-based violence service provision and policy through evidence-based advocacy. Despite working within a complex and inequitable developing country context, where our feminist praxis is frequently pitted against seemingly intractable structural realities, it is a praxis that remains grounded in documenting the stories of vulnerable individuals and within a broader political project of working towards improving the systems that these individuals must navigate under challenging social and structural conditions. We primarily do this by working with non-governmental organisations (NGOs) providing gender-based violence services in research conceptualisation, design and implementation. This raises unique and complex questions for feminist participatory research, which we illustrate through a case study of collaborative, participatory research with NGOs to improve health and criminal justice outcomes for survivors of sexual violence. Issues include the possibility of good intentions/good research designs failing; the suitability of participatory research in sensitive service provision contexts; the degree(s) of engagement between researchers, service providers (collaborators/participants) and research participants; as well as our ethical duties to do no harm and to promote positive, progressive change through personal narratives and other forms of evidence. Given the demands of our context and these core issues, we not only argue that there are no ‘feminist methods’, but also caution against the notion of a universal ‘feminist methodology’. Whilst we may all be in agreement about the centrality of gender to our research and analysis, the fundamental aims and assumptions of mainstream (Western) feminist approaches do not hold true in all contexts, nor are they without variance in mode, ideal degrees of participation and importance to social context.

Help, harm or hinder? Non-governmental service providers’ perspectives on families and gender-based violence against women with intellectual disabilities in South Africa

Abstract Through in-depth interviews with service providers from non-governmental organisations (n = 58), this article describes the intricacy of familial relationships for women with intellectual disabilities in South Africa who experience gender-based violence. The findings suggest that families navigate social stigma, limited resources and isolation, whilst trying to be vigilant against gender-based violence and disability-related violence, and respond to it as it happens. However, family members are also simultaneously implicated in violence perpetration. We suggest that a social relational model of disability could help account for these crucial intra-familial dynamics.