1. Rape, in numbers

During Women’s Month, there always seems to be a greater degree of outrage at sexual assault: how could this happen in a month of awareness? But for the victims, perpetrators and those who try to assist them, August is no different from any other month. Why should it be?

The new report by MSF, Untreated Violence: The Need for Patient-centred Care for Survivors of Sexual Violence in the Platinum Mining Belt, was launched at noon on Tuesday at the first National Conference on Violence in Johannesburg.

The report, based on interviews with 800 women (aged 18-49) in the Rustenberg area, found that one in four women was raped at least once during her lifetime, but 95% of the women who were raped never told a medical professional. Less than half of those surveyed knew that treatment was available to prevent HIV after a rape.

The numbers are disconcerting: 25% of survey participants personally knew a woman who had been raped; 6% personally knew a man who had been raped, and 21% knew a child who had been raped.

“There is a clear imperative to raise awareness among communities about where to access services and the benefits of medical attention after rape,” Dr Amir Shroufi, MSF Medical Co-ordinator in South Africa, said. “Timely access to care can prevent negative health consequences, including the risk of contracting HIV and other infectious diseases.”

The report found it was “imperative” to increase the number of professional staff trained in forensic examination, as well as the number of primary healthcare facilities that offered essential medical and psychological services.

This will be a big change: At present, only 4% of respondents who had been raped told a counsellor and only 3% told a social worker that they had been raped. Just one in five tell anyone at all. Those who do speak out very seldom tell police (8%).

All rape survivors should receive access to comprehensive medical and psychosocial care, said Dr Shroufi, although it was just as important for all survivors to have the option of undergoing forensic examination and pursuing legal action.

The report includes some startling statistics: researchers found that around half of the survey respondents had experienced either sexual violence, intimate partner violence (IPV), or both. A quarter of the participants had been raped in their lifetime, and the majority had been exposed to IPV. Women raped by partners tended to experience rape more frequently – among currently partnered women, two-thirds had been raped more than once by their primary partner, with 15% having been raped “many times”.

Most of the women surveyed were aware of the consequences of rape, including possibly contracting HIV, falling pregnant, or being injured. Yet less than 75% of women knew that pregnancy could be prevented after rape and just 45% were aware that there was prophylactic treatment available to prevent HIV.

“Treatment and psychosocial counselling for rape survivors reporting within 72 hours can prevent HIV infection and unwanted pregnancy, and help to mitigate long-term psychological suffering,” said MSF epidemiologist Sarah Jane Steele, “but the majority of women we interviewed don’t know such treatment exists, services close to where they live are sorely lacking, and lack of financial independence may make access difficult even when services are present”.

2. The Platinum Belt

South Africa has a bad rep for violence in general and gender-based violence in particular. While the country was still absorbing the controversial #RememberKhwezi protest this week, a six-year-old boy was beaten to death for trying to defend his mother from a rapist. In 2013, the shooting of Reeva Steenkamp highlighted that three SA women are murdered every day. South Africa is the global rape capital, and its femicide rates are five times the global average.

Zooming in on the platinum belt, the area of Greater Rustenberg, an hour’s drive from Johannesburg, is home to numerous mining towns. Places of interest in the surrounds include Hartbeespoort, the Magaliesburg, Rustenburg, Sun City, Madikwe, Zeerust, Brits, Marikana, Randfontein and Derdepoort.

Rustenburg itself sits within the Bojanala Health District where MSF, in partnership with the North West Department of Health, is piloting the expansion of a patient-centred response to sexual violence. This includes a clinical mentorship programme for professional nurses on the care and management of sexual violence, for the district’s people.

Unlike in the rest of South Africa, the majority of people living in Rustenburg are men. This is due in part to men making up the overwhelming majority (89%) of mineworkers, many of whom come from rural areas of South Africa and surrounding countries.

Unemployment is particularly high for migrant women, which is bad news for those fighting sexual assault. Many women live in economic conditions that promote dependency on men, who are more readily employed by mines in the area. If they suffer abuse at home or at work, many feel trapped.

In 2015, Amplats made headlines for the rape of one of its female employees in a changing room. Before that, Al-Jazeera wrote of the perils female miners faced, following the brutal rape and murder of Pinky Mosiane in a Marikana mine. A female miner said at the time: “There are only two toilets in the section… It’s so far to walk and it’s dark, dark, dark. Even if you scream, no one is going to hear you.” She added that if a woman were to be raped, she would probably not report it, for fear of losing her job.

Yet mining still holds its appeal. The local economy in the Rustenburg area is largely propelled by the extraction of platinum-group metals from the Bushveld Igneous Complex, the world’s largest repository. About 50% of people in the Rustenburg area rely directly on the mines for employment.

Despite ongoing distress in the mining industry, the climax of which was the Marikana massacre, the promise of jobs has lured hundreds of thousands of people to the area over the years. The population of Rustenburg increased by 78% between 1996 and 2011, from 308,903 to 549,575 people. It’s still said to be the fastest-growing municipality in the country. The majority of its residents are Black African.

And it’s not just the population that’s growing. The Rustenburg Local Municipality has been identified as an HIV/Aids hotspot, with what local government previously described as “a 37.3% increase in individuals that have HIV/Aids in the North West province, and a staggering increase of 49.2% in the Rustenburg Local Municipality”. Sexual assault, reports MSF, is inextricably linked to the HIV epidemic.

Extrapolating the study’s figures, MSF says about 11,000 women and girls in Rustenburg are raped each year, or 55,000 in the Rustenberg Local Municipality. Nonetheless, healthcare coverage in the area is low compared to the high concentration of people living and working there.

“The presence of mines creates economic growth for some, but at the same time, many who migrate to the mining areas in hope of finding work are unsuccessful, or receive low levels of remuneration,” reads the report. “Consequently, a large number of informal settlements have developed around the mines in recent years, many of which are characterised by ‘grim poverty, the absence of government services, limited basic infrastructure, no running water and poor sanitation’.” Consequently, it adds, the communities that live alongside one of South Africa’s biggest industries are particularly vulnerable to violence, financial dependence on others, and disease.

Although the Bojanala Health District serves about 1.3-million people, the North West Department of Health has confirmed that there are just 11 designated health facilities, including MSF’s, that provide Post-Exposure Prophylaxis (PEP) and support forensic examination for survivors of rape, out of 783 health facilities in the district. There is only one Thuthuzela Care Centre providing dedicated support to sexual violence survivors. It is led by, among others, the NPA Sexual Offences and Community Affairs Unit.

Rape has far-reaching effects for both individual and society. Despite Mr Turner Senior’s assertions that son Brock was being victimised for “20 minutes of action”, the consequences of sexual abuse are, in fact, severe. Rape is born within a cycle of violence, but also perpetuates it.

Apart from the physical risks – of injury, death, or disease – the intangible effects are felt for years after an assault. Rape victims also have an increased risk of being raped again.

“Psychological suffering from rape is widespread and can be severe; for example, depression as well as alcohol use disorders are five times more common in survivors,” the researchers wrote. “Rape can also be fatal – perpetrators may kill their victim, and survivors are more than four times more likely to take their own life.” High levels of sexual violence are inextricably linked to SA’s HIV prevalence, they added. Even forced oral sex can cause lesions, which increase chances of HIV transmission.

The Rape, Abuse & Incest National Network (RAINN) reports that 94% of women reported PTSD symptoms following a rape, which often persisted for months afterwards. A third of women who are raped contemplate suicide and just shy of 15% actually attempt it. Approximately 70% of sexual assault victims of any description experience moderate to severe distress, a larger percentage than for other violent crimes. Additionally, sexual assault victims of all genders and ages are up to 10 times more likely to abuse drugs. Victims widely report experiencing problems at work or school, increased aggression after the assault, and feeling unable to trust family or friends. Rape is also twice as likely to result in pregnancy than one-time unprotected sex normally would.

Yet healthcare and support remain a major challenge in the Rustenburg Local Municipality. According to the survey, those who do access healthcare services often do so late. Based on data from Kgomotso Clinic, among those survivors who do access care, half don’t do so within the 72-hour time window where they are eligible for services. In this critical time, emergency contraception works best, but it’s also the time frame in which prophylactic treatment for HIV is effective.

3. It’s everybody’s problem

Sexual violence in the platinum belt – as elsewhere – is not just a women’s issue. In addition to rape falling within a cycle of violence, there are more at-risk groups than one might like to think. Of Kgomotso Clinic clients from the end of July 2016, says the report, 11 survivors of sexual violence were men. More than one study – locally and abroad – has claimed that one in 10 men are victims of sexual violence in their lifetime. Globally, trans* people are at even higher risk than non-trans* women. According to Kgomotso Clinic, there was also a significant number of child victims in the above-mentioned time period.

Although the report found that children are more likely than adults to report sexual violence, reporting rates overall were very low. Men especially faced “particular challenges in seeking or accessing care”, wrote the report’s authors.

According to RAINN, “Men and boys who have been sexually assaulted or abused may have many of the same feelings and reactions as other survivors of sexual assault, but they may face some additional challenges because of social attitudes and stereotypes about men and masculinity.”

Patriarchy does not create only male perpetrators, but also male victims. This same gender inequality places trans* people at the highest risk of all.

The MSF report found that while almost all women surveyed knew that both women and children could be raped, one third of the participants believed a man could not be raped. Among those that believed a man, woman or child could be raped, 14% believed a man could be to blame for their rape and 16% believed the same of women.

4. Moving forward

MSF, says spokeswoman Angela Makamure, is calling for a co-ordinated response from South African local governments involved in responding to sexual violence. “Policies such as the next five-year National Strategic Plan for HIV, TB and STIs should monitor the financing and implementation of a patient-centred approach to sexual violence, both around Rustenburg and nationally,” Makamure said in a statement.

The researchers stressed that a basic package of healthcare services could mitigate or prevent adverse health consequences of sexual violence, if these were provided timeously. A total care package, they said, should include PEP for HIV, emergency contraception where applicable, and supportive counselling. Providing forensic examination at the facility where the first consultation took place could support the legal process for those who wish to press charges, they added.

Other barriers would also need to be overcome: stigma, particularly among medical staff and police, but also within communities. “Roughly a third of women surveyed indicated that the staff at their local clinics [were] not approachable, with a similar proportion considering staff not trustworthy,” the report noted. “If survivors do not perceive staff as being empathetic to the trauma of experiencing rape or sexual violence, then they may be less likely to seek care or disclose their experiences.”

“Many women are afraid of reporting rape because they fear public embarrassment, judgement by staff, and being isolated in their community,” one participant explained. In fact, 95% of respondents indicated that a victim of sexual assault might face stigma in one form or another.

In addition to overcoming stigma, the report noted that attention would also need to be given to the economic inequality along gender lines, which left so many vulnerable women dependent on their abusers, or on jobs where they faced regular violence and/or harassment. Education about both sexual violence and the associated support available was crucial, the report stressed.

And last, proximity to facilities – as well as the availability of follow-up services – needed to be tackled. (In perspective, there are just 7.7 social workers per 100,000 people who work directly in welfare activities in North West — by comparison, the Northern Cape and Western Cape respectively have 20.4 and 15.7 social workers per 100,000 people.)

The authors propose integrating rape support to existing clinic facilities.

“Survey findings suggest that while very few women seek medical attention following incidents of rape, women do attend health facilities for any number of reasons – 60% of women surveyed had accessed their local clinic in the previous six months,” they wrote. “This suggests that screening for sexual violence in clinics may provide an opportunity to link more survivors of sexual violence to care.”

Several government departments — including the North West Department of Health, Department of Social Development and NPA — had a responsibility to ensure their approach to addressing sexual violence supported access to a medical response for survivors, the report added. “Yet a co-ordinated interdepartmental approach to achieve this vision is lacking.”

Perhaps such co-ordinated efforts can – eventually – slow down the cycle of violence. Meanwhile, above ground and below it, the platinum belt battles on. DM

Read the full report here.

Photo: A settlement known simply as RDP, near Lonmin’s K4 shaft, Mariakana. Photo Greg Marinovich