A Case Study on Transdisciplinary Approach to Eradicating Sexual Violence: Thuthuzela Care Centres

Abstract

In 2010, South Africa had the highest rate of rape in the world at 132.4 incidents per 100,000 people; this decreased to 72.1 in 2019–2020. This could be an actual decline, or it could be due to other factors such as a sign of decrease in reporting and lack of trust in the criminal justice system. Executing its mandate to develop best practices and policies in the reduction of gender-based violence, the Sexual Offences and Community Unit (under the National Prosecuting Authority) introduced Thuthuzela Care Centres (TCCs) in 2006, one-stop facilities whose aim is to turn gender-based violence (GBV) victims to survivors through psychosocial, medical and legal support. A transdisciplinary approach is utilised in solving national challenges, including Departments of Justice, Health, Social Development, Treasury, and Non-Governmental Organisations who work with social workers to offer counselling. TCCs are the most cohesive intervention to date that seeks to prevent and eradicate GBVF. Accountability by each stakeholder from the opening of the case to its conclusion has improved conviction rates tenfold. The country requires more partnerships and transdisciplinary approaches to tackle national challenges, including SGBVF. It will take leadership and accountability by all parties to achieve success.

1. Introduction

World Health Organisation ([1]:2) defines sexual violence as: ‘Any sexual act, attempt to obtain a sexual act, unwanted sexual comments, or advances, or acts to traffic or otherwise directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work’.

Coercion can encompass varying degrees of force; psychological intimidation; blackmail or threats (of physical harm or of not obtaining a job/grade, etc.).

In addition, sexual violence may also take place when someone is not able to give consent—for instance, while drugged, intoxicated, asleep or mentally incapacitated. Sexual violence includes but is not limited to: rape within marriage or dating relationships (intimate partner); rape by strangers or acquaintances (non-partner); unwanted sexual advances or sexual harassment (at school, work, etc.); systematic rape, sexual slavery, and other forms of violence, which are particularly common in armed conflicts (e.g. forced impregnation); sexual abuse of mentally or physically disabled people; rape and sexual abuse of children; and ‘customary’ forms of sexual violence, such as forced marriage or cohabitation and wife inheritance.

There are numerous sources of data on the prevalence of sexual violence, including police reports, studies from clinical settings and non-governmental organisations and population-based surveys [2]. The latter is reported to have the best quality of data, with general underreporting of sexual violence. Reasons vary from lack of trust in the criminal justice system, shame, inadequate support systems, fear or risk of retaliation, fear or risk of being blamed, fear or risk of not being believed to fear or risk of being mistreated and/or socially ostracised [1]. The prevalence varies according to the type of violence and geography. In a cross-sectional survey amongst a randomly selected sample of men in South Africa, 14.3% of men reported having raped their current or former wife or girlfriend [3], while in a WHO multi-country study, lifetime prevalence of sexual partner violence reported by women, aged 15 to 49 years, ranged from 6% in Japan to 59% in Ethiopia, with rates in most settings falling between 10% and 50% [4]. Most available data on sexual violence by a non-partner are from crime surveys, police and justice records, rape crisis centres and retrospective studies of child sexual abuse [5]. In 80% of rape cases in the USA, the aggressor is known to the woman (victim) [6, 7]. Meanwhile in South Africa, the most recent survey of the prevalence of rape found that more than one in five men reported raping a woman who was not a partner (i.e. a stranger, acquaintance or family member), while one in seven reported raping a current or former partner [3]. Sexual violence is prevalent in all societies across geographies and social classes.

2. Underlying factors to sexual violence

Sexual and gender-based violence and femicide (SGBVF) is about gendered power inequality, which is rooted in patriarchy [8]. Culture and social beliefs play an important role in sexual violence; a culture of violence and male superiority tends to normalise violence against women and children, all forms of violence. This culture extends to safety and security officers who are supposed to protect women. When women report sexual violation and are subjected to secondary victimisation by police, where their account is not believed, this causes more emotional harm and delayed healing and discourages women from reporting crimes [9]. The culture of victim blaming, stereotyping and secondary victimisation of victims of SGBV by police is rife globally [10, 11, 12]. This is despite several studies that confirm the low rate of false reporting on sexual assault. A meta-analysis of seven studies found that the actual rate of false reporting (e.g. lying) about sexual assaults was low, approximately 5% [9].

In South Africa, different forms of violence date back to the violent apartheid system, which legislated for and institutionalised different forms of violence to control and repress the majority [13]. South Africa was listed in the 2018 Global Peace Index as one of the most violent and dangerous places on Earth which is not abating [13]. Galtung [14] described three types of violence, direct, structural and cultural. Direct or personal violence includes sexual violence and is enabled by easy access to weapons, a general climate of lawlessness and corruption within the criminal justice system [13]. Underlying direct violence is structural violence, defined as personal and social violence, entrenched in unequal power relations embedded within society. The unequal power relations are gendered and racial and determine access to quality health and education [13]. Structural violence arises from unjust, repressive and oppressive political, economic and social structures that affect people’s chances in life, while cultural violence is based on attitudes and beliefs that perpetuate discrimination, racism, prejudice and sexism. Systemic institutionalised patriarchy legitimises violence against women.

3. Role of men

Violence by men is associated with a patriarchal system and toxic masculinity.

Toxic masculinity, a term coined by Shepherd Bliss (in [15]), is toxic behaviours by men as a reaction to perceived threats to the masculinity of a subset of men with poor self-esteem. Scholars posit that being a man is valued by most societies, while being a woman is devalued; therefore, when men who lack self-esteem do not receive external validation, it triggers toxic behaviour to ‘regain’ their masculinity. Many studies describe how young men have identified violence as an important way to display power and to prove their masculinity in their communities, including exerting control in intimate relationships with women. According to October [16], toxic masculinity is when the norms of masculinity that are defined as violent, unemotional and sexually aggressive have a harmful impact on society and the individual. However, toxic masculinity goes beyond that; male rape is severely underreported because vulnerability is constructed within gendered notions of femininity; negating the victim’s masculinity, the violence affirms the masculinity of the perpetrator [16]. While most programmes designed to prevent GBV focus on women and how they should protect themselves, interventions to end gender-based violence need to involve men and boys to help them change their attitudes and behaviours, and even renegotiate their social position and identity [17]. Positive masculinity requires deliberate and consistent effort by all stakeholders to achieve social cohesion and a culture that celebrates equality across all social identities. In South Africa, a few intervention programmes have shown positive behaviour change amongst men and boys, such as One Man Can, Men as Partners and Steppingstones; however, a national roll-out is required to have sustainable change [18].

Most sexual violence is committed by male perpetrators; therefore, involving men and boys in prevention efforts requires holding them accountable for the ways that they contribute to sexual violence; they must be a major part of the solution of creating a culture free from gender-based violence [19]. It starts by raising responsible, sensitive young boys and girls who see all human beings as equals. Men and women need to unlearn the gendered socialisation, gendered roles and prejudice. More programmes are needed that are designed to teach boys and men acceptable behaviour towards women and people who are different from them. One such programme is Futures Without Violence’s Coaching Boys Into Men (CBIM) programme, by Centres for Disease Control and Prevention (CDC), which teaches high-school athletes healthy and respectful behaviour to prevent GBV. CBIM teaches young athlete men that violence does not equal strength. Another area that does not receive enough attention, research and resources is the rehabilitation of sex offenders. There is not enough research on the different sex offender intervention programmes and their effectiveness on young and/or adult offenders; the ‘Good Lives Model’ and/or Standard Relapse Prevention Programme, amongst other models, especially amongst young offenders [20]. Investment in research in the effectiveness of each model per age group will ensure that research informs evidence-based solutions.

4. Response to sexual and gender-based violence and femicide: Thuthuzela Care Centres case study

‘Violence against women (in South Africa) is a social problem produced by choices made by corporations, governments, politicians, faith-based organisations, and individuals… It is not a crisis out of our control but a social condition that can be interrupted through deliberate efforts’ [21].

According to the World Population Review [22], in 2010, South Africa had the highest rate of rape in the world at 132.4 incidents per 100,000 people; this decreased to 72.1 in 2019–2020. While this is still in the top 3 in the world, it is going in the right direction. This could be a real decline, but it could also be a sign of decrease in reporting due to various factors, including lack of trust in the criminal justice system [23]. The South African government has promulgated progressive laws to address gender equity in general and gender and domestic violence specifically; however, the numbers remain very high. Civil society has been instrumental in driving the progressive laws and initiatives to combat SGVBF. One of these coalitions is the Shukumisa Coalition (Shukumisa means shake up in Nguni language), which has over 60 organisations whose focus is fighting sexual violence against women and children. In 2018, during the month of August, thousands of women and gender non-conforming people (GNC) took to the streets of South Africa under the banner of the Total Shutdown Movement (TTS), demanding intervention by the government and businesses to end the high rates of gender-based violence (GBV) against women and GNC people. This led to a National Summit on Gender Based Violence and Femicide which brought together the government, the Total Shutdown Movement and various civil society organisations; the summit concluded with the signing of a declaration that the government, businesses, labour and civil society would collaborate to conceptualise, drive and implement concrete measures to eradicate gender-based violence and femicide [24]. The National Strategic Plan (NSP) for GBVF was a product of this collaboration; see Figure 1 below.

Figure 1.

National Strategic Plan for GBVF. Source: www.dsd.gov.za.

The NSP is a multi-sectoral, coherent strategic policy and programming framework developed to strengthen a coordinated national response to the crisis of GBVF by the Government of South Africa and the country. The six pillars require a multi-sectoral and transdisciplinary coordination of effort to eradicate SGBVF. The NSP follows many different initiatives by the government to curb the scourge of GBVF. One of these was the establishment of a special unit, the Sexual Offences and Community Unit, in 1999 under the National Prosecuting Authority (NPA) within the SA government’s Department of Justice. Thuthuzela Care Centres are an initiative under SOCA.

4.1 Sexual Offences and Community Unit (SOCA): Thuthuzela Care Centres

The Sexual Offences and Community Unit (SOCA) is responsible for the SGBVF mandate of the NPA. SOCA is led by a special director. The responsibilities of the directorate, as shared in the South African government official website, include¹:

1. The formulation of policy regarding capacity building, sensitization and scientific functional training in respect of the prosecution of sexual offences.

2. The coordination of the establishment of Special Courts for the adjudication of sexual offences.

3. The facilitation and/or formulation of research techniques for the prosecution of sexual offences.

4. The development and implementation of community awareness programmes and of plans for the participation of non-governmental organisations in processes and procedures aimed at the prevention or containment of sexual offences.

5. The development of training and plans and mechanisms regarding the prosecution of sexual offences.

6. To establish a specialised unit against violence on women and children and perform all these functions in respect of Gender Based Violence, Domestic Violence, Maintenance, Child Offender Management and Human Trafficking.

Executing its mandate to develop best practices and policies in the reduction of gender-based violence, the SOCA unit introduced Thuthuzela Care Centres (TCCs) in 2006. Thuthuzela means to comfort in one of the South African languages, isiXhosa. TCCs are one-stop facilities whose initial aim was to address rape victims. The mandate has since expanded to include all victims of GBV. This initiative is one example of a transdisciplinary approach in solving national challenges. Each centre is hosted within a health institution, hospital or clinic and is linked to one or more police stations. It is a collaboration between the NPA (Department of Justice), Department of Health, Department of Social Development, Treasury Department and non-governmental organisations (NGOs) who work with social workers to offer counselling.

4.2 Sexual Offences Courts (SOCs)

The Sexual Offences Courts are dedicated to sexual violence cases; they are victim centred through provision of a victim-friendly place, CCTV equipment (for victims to testify in camera), a special victim testimony room and a private waiting room. Regarding human resources, each court should have a presiding officer, two prosecutors, an intermediary, an interpreter, a designated court clerk, a designated social worker, a legal aid practitioner and an official to help with court preparation, including provision of counselling services by social workers [25]. The first sexual offences court was opened in Wynberg, Cape Town (SA), in 1993. The conviction rate was up to 80%, which was very high compared to ‘general’ courts (4–6% at the time for similar crimes). Around 2005, there were about 74 SOCs in the country. Due to various reasons, including funding, there was a moratorium on the SOCs. ‘In 2020, section 55A of the Criminal Law (Sexual Offences and Related Matters) Amendment Act was signed into operation meaning that for the first time Sexual Offences Courts are being established in accordance with a statute’, explained Deputy Minister of the Department of Justice, [26]. He continued to explain that the regulations relating to section 55A stipulate support that should be given in section 55A SOCs, namely, court support, court preparation, emotional containment, trauma debriefing, counselling, private testifying service, intermediary services and information services. Sexual Offences Courts work closely with TCCs to ensure that a victim-centred and holistic integrated service is being provided to victims.

4.3 The stepwise approach at TCCs

The one-stop shops are well coordinated through collaboration across disciplines. The layout design enables a stepwise approach, which ensures efficiency and protection of the victim from the time she walks into the centre. Below are the different steps that victims go through and the department responsible for each step:

1. Victim assistance by the victim assistant officer and/or site coordinator—NPA (Department of Justice).

2. Medical examination and forensic extraction of evidence—Department of Health (DOH)—by a doctor or nurse or both.

3. After the medical examination, there are bath or shower facilities for victims’ use, restoring the survivor’s dignity.

4. An investigation officer will interview the survivor and take his/her statement—South African Police Services (SAPS).

5. A social worker or counsellor will offer counselling—Department of Social Development (DSD)—assisted by NGO workers.

6. Arrangement for follow-up visits, treatment and preventative medication for sexually transmitted infections (STIs), HIV and AIDS—DOH.

7. A referral letter or appointment will be made for long-term counselling—DSD/NGO.

8. The victim (survivor) is offered transportation home by an ambulance or the investigating officer—DOH/SAPS

9. Referral to a shelter or place of safety, if necessary—DSD/NGO

10. Consultations with a specialist prosecutor before the case goes to court—NPA.

11. Court preparation by a victim assistant officer—NPA

12. Explanation of the outcome and update of the trial process by a case manager—NPA.

This holistic approach helps to increase the conviction rate by building a case ready for successful prosecution, offering psychosocial support to victims/survivors and reducing the cycle times of these cases from reporting to finalisation. The current sites for TCCs were identified based on various criteria, including the volume of sexual offence cases reported at the local SAPS (police stations); the number of sexual offence cases dealt with at the local court/s; availability of space at the local hospital; presence of SAPS Family Violence, Child Protection and Sexual Offences (FCS) unit; availability of non-governmental services for victims and stakeholder buy-in (Figure 2).

Figure 2.

The Thuthuzela Care Centre model. Source: www.npa.gov.za

According to the South African government website, as at September 2022, the number of TCCs was 58¹. Though the funding of the TCCs is from the government, the private sector is encouraged and is starting to assist in the building of more TCCs, including using private hospital sites, provided the site is linked to a police station. Support from the private sector includes donations of equipment. Working with the Gender Based Violence & Femicide Response Fund, the Minerals Council of South Africa and the custodian of TCCs, the NPA, signed a memorandum of agreement to work together to support the Thuthuzela Care Centres for victims of gender-based violence, with a particular focus on mining communities and/or labour-sending areas.²

4.4 Roles and responsibilities of different departments

The roles and responsibilities of the different departments in the TCC collaboration are as follows [28]:

4.4.1 National prosecuting authority under department of justice

• Overall TCC coordination

• Appointment of site coordinators, victim assistant officers and case managers

• Case management of criminal case

• Court preparation of victims

• Sexual offences courts

• Operational costs related to the TCC

4.4.2 Department of health

• Provide healthcare workers emergency medical services

• Medical treatment

• Forensic investigation

• Provision of PEP, vaccinations, STI prophylaxis, emergency contraception

• Cleaning services

• Security

• Maintenance

4.4.3 South African police services

• Charge office that is victim-friendly and trauma-informed

• Charge officers who are sensitised to the victim’s needs and issues of sexual victimisation

• Obtain the victim’s statement

• Sexual assault evidence collection kits (SAECK)

• Transport for services

4.4.4 NGOs

• Counselling

• Comfort kits—hygiene products for victims of violence, including toys for victimised children. Food and clothing when possible

• Follow-up psychosocial support

• Assist with 24/7 service delivery

4.4.5 Department of social development

• Victim support

• Counselling services

• Emergency shelter services

• Appointment of social workers and counsellors (Figure 3).

Figure 3.

TCC sites in South Africa as of February 2022. Source: www.justice.gov.za.

4.5 Success factors of the Thuthuzela Care Centres

The success of the TCC model lies on at least five pillars: victim-centred, court-directed, multidisciplinary approach, policies that empower different service providers in tackling SGBV and successful coordination of all services amongst different departments.

4.5.1 Victim/survivor-centred

Services are tailored to the victim’s needs, and secondary victimisation is reduced by creating a victim-friendly environment, safe and conducive to reporting and retention. Trained professional personnel empower the victim through psychosocial support and legal preparation for the court cases. Trust is built due to clear and accurate feedback at all stages of the journey for the victim.

4.5.2 Court-directed

Offender accountability is ensured by using a systematic approach through trained specialised personnel. This includes securing physical and forensic evidence by trained personnel from the victim/survivor and focused, prosecutor-guided investigation. Having specialised courts linked to the TCCs ensures speedy and seamless prosecution process. There are NGOs that specialise in training victims on how the legal system works in preparation for the court case.

4.5.3 Multidisciplinary approach

No one department can solve the complex challenge of SGBV. Cooperation amongst role players, from health and forensic workers, police, treasury, correctional services, designated civil society organisations, social workers and counsellors to prosecutors, is key for successful prosecution and empowerment of the survivors. Ensuring accountability of each stakeholder with shared objectives and effective leadership is required for the multidisciplinary approach to be effective.

The direct link between the TCC, the SAPS FCS, the hospital and sexual offence court, where the matter will be heard, is a seamless transdisciplinary approach. Linking TCCs to GBVF hotspots ensures easy access for victims where the need is the highest.

Policies and Regulatory Framework that empower stakeholders together with leadership in coordinating a seamless service provision play an important role in the attempt to prevent and eradicate SGBVF.

4.6 Impact of Thuthuzela Care Centres

Data from the past 5 years show that cases from the TCCs have attracted more severe gaol sentences on the offence of rape specifically in courts, with 15 to 18% of cases getting life imprisonment for perpetrators. Public awareness campaigns are run by TCCs (designed by SOCA) to empower surrounding communities. The raised awareness has increased reporting levels, though there is still a long way to go. South Africa has one of the highest HIV/AIDS cases in the world. Provision of post-exposure prophylaxis (PEP) by TCCs forms a critical component of reducing the transmission of HIV/AIDS; thus, TCCs are a crucial component in the fight to reduce the transmission of HIV/AIDS. This service attracts victims even if they have no intention of opening a case against a perpetrator.

4.7 Challenges

The location of TCCs is partly determined by rape hotspots as reported by the police stations. The way the hotspots are selected is challenged by scholars. Between April 2008 and March 2009, 12,093 women in Gauteng, or 0.3% of the province’s adult female population, reported an assault by an intimate partner to the police; by contrast, during the same period, 18.1% of women in the province reported an experience of violence at the hands of intimate male partners to researchers [23]. Lack of trust in the criminal justice system maybe one of the reasons for underreporting at the police station. The second challenge with the accuracy of the identification of hotspots is the system used by the police of ranking informed only by the total number of cases reported, which produces lists with a predominance of stations serving densely populated areas, as opposed to looking at the number of crimes relative to the size of the population. The inaccuracy of reporting leads to misallocation of resources, including the TCCs. The ‘misreporting’ leads to loss of resource allocation where the need is high.

The ideal design for TCCs has a separate entrance for perpetrators, to ensure protection of victims. However, a compliance audit and gap analysis report showed that only 52% of TCCs have a separate entrance for perpetrators [28]. This could have improved over the past 5 years. The same report acknowledges that the majority of TCCs operate according to the TCC Blueprint; half the TCCs offered more services than those prescribed, like age estimation, shelter offering and DNA testing of suspects. The structure of the facilities is key to ensure a seamless service delivery. Lack of adequate fund allocation to the TCCs programme is critical in ensuring that the facilities, the equipment used and the personnel are fit for the purpose. Funding cannot be overemphasised for the success of this programme.

Having adequate number of trained personnel in the different steps of the TCC Blueprint determines the success of the programme. However, not all personnel are available 24/7, which requires victims to come back for part of the service during office hours. Transport is another issue; transport by the SAPS and/or by the victim is another challenge that needs to be addressed. This has a major impact on visits to court and follow-up psychosocial-support visits by victims, especially low-income/unemployed victims who do not have their own transport, who happen to be in the majority.

There is a need for a sustainable, consistent and stable funding environment to ensure that the necessary services can be delivered at all TCCs [28]. Funding, especially of NGOs, is one of the main challenges to service delivery.

Coordination amongst departments is not always at the correct level to ensure that the service is efficient. Enforcement of the progressive laws in the country is lacking in a few areas of the criminal justice system, which hinders successful and timeous conclusion of cases.

There are not enough TCCs to address the challenge of GBV. The country has 155 Family Violence, Child Protection and Sexual Violence SAPS units, with only 57 TCCs. Ideally, there should be one TCC for each unit.

5. Conclusion

South Africa has a history, during apartheid days, of condoning violence against most of the population along racial and gender lines. The past apartheid laws were dehumanising to the majority and broke family units. These challenges were not adequately acknowledged nor addressed when the new dispensation was ushered. Patriarchy and masculine toxicity normalise all forms of violence against women and children. Achieving social cohesion, one of the ingredients to SGBVF prevention (Pillar 2 of the NSP-GBVF), is an important and common thread that needs to override and bind all interventions. Progressive laws need to be well implemented by the responsible stakeholders to achieve what they are set for. Lack of accountability and leadership (Pillar 1 of the NSP-GBVF) underpins all success in tackling big and small challenges. Justice (Pillar 3 of the NSP-GBVF) brings back trust in the criminal justice system and plays a role in preventing repeat offences. Research (Pillar 6 of the NSP-GBVF) to understand root causes and understand what works and what does not helps in the design of evidence-based solutions. Lastly, achieving economic equality across genders (Pillar 5 of the NSP-GBVF) empowers women to leave toxic relationships and helps them to value their worth in society. All the above are ingredients of a progressive and cohesive nation that has the potential to prosper. Leadership and accountability of each citizen and leaders across all sectors of society cannot be underestimated. The transdisciplinary approach that delivered the comprehensive NSP for GBVF was a good start to find solutions. However, like any plan, effective implementation is what determines success.

Thuthuzela Care Centres are the most cohesive and transdisciplinary intervention to date that seek to prevent and eradicate sexual and gender-based violence & femicide. Accountability by each stakeholder from the opening of the case to its conclusion will improve the results and edge the country closer to gender-based violence and femicide eradication. The country requires more partnerships and transdisciplinary approaches to tackle national challenges. The transdisciplinary approach of the TCC model can be that required solution to the sexual and gender-based violence and femicide crisis in the country. It will take leadership and accountability by all parties to achieve success.