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Shattered Lives: South Africa
One-Stop Center for Survivors of Sexual Violence in Khayelitsha
March 4, 2009
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The levels of sexual violence in South Africa are alarming: it is estimated that a woman is raped every 26 seconds18. Khayelitsha, a poor township on the outskirts of Cape Town, has one of the highest incidences of rape in the country. In Khayelitsha, survivors of sexual violence receive care at Simelela, a center offering comprehensive services that go far beyond basic medical needs in a unique partnership between MSF and numerous local partners. Simelela, which means ‘to lean on’ in Xhosa, one of the official languages of South Africa, is open 24 hours a day, seven days a week.
The high incidence of sexual violence in South Africa has been explained in many different ways. Some attribute it to the strong culture of violence in the country, whereas others blame it on the inadequate criminal justice system, which often fails to convict, and therefore deter, perpetrators. In places like Khayelitsha, lack of adequate housing and electricity make the victims even more vulnerable, as dark alleyways and houses that provide poor protection against break-ins offer little deterrence to aggressors. Substance abuse is often linked to sexual violence in Khayelitsha, as many reported incidents of sexual violence involve alcohol or drugs.
Although there is growing awareness of sexual violence in South Africa, rape survivors are often stigmatized and ridiculed. “People laugh at me and say, ‘Oh, you will get HIV/AIDS now’”, said Baba, a rape survivor in Khayelitsha. “These are my neighbours and people who live around me. They don’t seem to think the men that raped me did anything wrong”.
The rampant levels of hiv in the country make the fear of contracting hiv terrifying for survivors. “It was such a relief to discover i could receive treatment to stop me getting HIV/AIDS”, said a 28-year-old woman who was raped in Khayelitsha. “I was so worried after the rape that i would get sick. I didn’t think i could cope with that on top of everything else”.
Combining Services For Rape Survivors Under One Roof
South Africa 2009 © Bénédicte Kurzen
Simelela opened in 2003, offering counseling and follow-up care to survivors of sexual violence. At that time, the initial medical examination was performed at a hospital approximately 15 km from Khayelitsha. In august 2005, a partnership was formed with MSF, the South African Government’s Provincial Health Department, other government departments and nongovernmental organizations (NGO) to make the clinic into a comprehensive centre providing care 24 hours a day, seven days a week. MSF played a coordinating role, also providing medical expertise on care for survivors of sexual violence in Khayelitsha. As a result, a range of emergency and follow-up services are now integrated under one roof. In the first year of functioning 24 hours a day, seven days a week, the number of survivors of sexual violence seeking assistance at the center more than doubled. “Before, the center would receive between 300 to 400 patients a year. When it became a multidisciplinary center, the numbers went up to 600 patients per year”, said Dr. Genine Josias, a doctor who works at the clinic. In 2008, 1,075 new patients were treated at the center. Eighty percent of the rape cases arrived within 72 hours.
At Simelela, a team of doctors and nurses offer emergency and follow-up medical care to survivors of sexual violence, including counseling. During the first consultation, patients receive detailed information about the process of forensic examination - a thorough examination that looks for injuries and takes samples that may be used as evidence in a police investigation and any subsequent prosecution - and how to file a complaint and press charges, if they wish. When they do, a police officer is called to the center to take a statement through a collaboration with the Family violence, Child Protection and Sexual Offenses Unit at the South Africa Police Services (SAPS). “The police department is an integral part of our multidisciplinary team”, explained Tara Appalraju, MSF project coordinator at Simelela. “The police are trained to deal with survivors of domestic violence, sexual violence and child abuse. Anyone can phone the police if they need urgent help, and the police will go to where the clients are to escort them to Simelela or to the police station. The statements are always taken at Simelela.” Today, 83% of the patients file a complaint with the police.
Forensic evidence is thoroughly collected by specialized forensic examiners at the center, following government protocols. Semen or hair found in the body of the victim contain DNA material that can help identify perpetrators in a court case. However, due to the absence of a national DNA database, forensic evidence can only help convict perpetrators when they are already known to the victim. A positive DNA identification of semen, however, is still not enough to confirm a rape, as it cannot determine whether consent was given prior to the sexual relation. When the perpetrator is unknown, the case rarely enters the court system.
Although follow-up care is also offered at the clinic, only 10% return for the 3-month follow-up appointment. “Many people do not have the money to pay for transport”, said Appalraju. “Some want to get this whole ordeal behind them, and coming for follow-up reminds them of this negative experience. Children sometimes do not have the support or solid family structures that ensure good care, many parents work and no other caregivers are available to bring them for follow-up”. A number of measures have been implemented to improve attendance of follow-up consultations, such as appointment cards and information booklets that explain their importance. “At the very first visit they have an information overload. There is all the counseling, medical and police information and sometimes it is too much for them to absorb, they just cannot cope”, explained Dr. Josias from the center. In 2009, the Simelela team will use telephone reminders to increase follow-up rates19. Many people in South Africa own a mobile phone.
More than half of the survivors arriving in Simelela are under the age of 19. According to South African legislation, these patients must be referred to social workers from the Department of Social Development. “The social workers undertake assessments and intervene accordingly. If the child is deemed in danger, he or she will be removed to a place of safety”, explained Appalraju.
Through Rape Crisis, a local NGO, survivors over 14 years old receive counseling. Children younger than 14 are referred to Nonceba Family Counseling Center, another local NGO. Both organizations have offices in Khayelitsha, enabling follow-up counselling to be done in the area where the survivors live.
To facilitate work with children, Simelela has a special room with toys and specifically trained counselors. Dolls and other toys are used to help children explain what happened to them, as very young children find it difficult to describe an act of sexual violence and/or lack the vocabulary to do so.
In 2009, the project will be handed over to Mosaic, a South African nongovernmental organization (NGO) that provides services for victims of sexual and gender-based violence. Mosaic was identified by MSF as a suitable organization to continue the management of the center. “We felt that it was unnecessary to establish our own NGO as this would lead to duplication”, Appalraju said.
Speaking Out Against Sexual Violence in Khayelitsha
South Africa 2009 © Bénédicte Kurzen
Effective awareness raising efforts, as well as the high quality and wide range of services offered at the center, are believed to be the main factors behind the steady increase of patients visiting the center. Awareness raising not only encourages survivors to seek help and promotes the services at the center, it also aims to improve prevention and reduce the stigmatization of sexual violence in the community. “Prevention is an essential part of the response, and only through challenging communities to examine assumptions that perpetuate violence can we hope to reduce the number of cases that continue to arrive at the Simelela Center every single day”, said Nonthuzelo Ntwana, center coordinator.
Newspaper articles, pamphlets, calendars, banners and t-shirts are some of the material produced by Simelela to promote awareness about the services offered at the center. Workshops, marches, door-to-door campaigns and regular talks on community radio also help highlight the issue and dispel common myths about sexual violence. These activities are carried out in partnership with the Treatment Action Campaign (TAC) and other local community-based organizations.
The activities also aim to educate people about what to do in case a friend or a relative becomes a victim of sexual violence. As anyone can be the first person a survivor goes to for support, disseminating information about how to listen without judging or blaming the victim, and who to contact is crucial to help people provide initial support to survivors of rape. in order to reach children and adolescents, a drama group was contracted to create a play about sexual violence and Simelela. “The group performs the drama in most schools in the community”, Appalraju said. “The teachers and students are then encouraged to produce their own play. Students from these schools gather to present their plays to one another. We are reaching more than 1,000 students per school between the ages of 8 to 13 years. Whenever the drama group goes to a school, we receive referrals of students who have been sexually violated”. Puppet shows are also organized in nurseries to raise awareness from a very early stage, as children make up a large part of the patients seen at Simelela. Sixty-one percent of attempted rapes reported at the center in 2007 were committed against children 6-18 years old. Young children under five years old are increasingly being seen.
Collaboration: A Key to Simelele's Success
To help raise awareness about rape in Khayelitsha, a number of governmental and nongovernmental organizations have joined efforts: TAC, Olive Leaf Foundation, Planned Parenthood Association of South Africa, SAPS, Mosaic, Department of Social Development, Department of Health and Rape Crisis. “We inform people about what to do if someone has been raped, where to go, what to expect, so they can give support to the people who have been raped”, said Fumana Ntlontlo, a survivor who has become a volunteer with TAC. “We support the family of the victim by helping in the court case against the perpetrator, we accompany the victim to court. If people come to us and they have been raped, we refer them to Simelela”.
As a result of the coordination efforts, a high-level team including justice, health, education, social development officials and NGOs meet regularly to evaluate performance and discuss ways to improve services. “The biggest challenge is to drive the partnership, to keep partners accountable to those we are trying to assist. The government understands that sometimes we have to speak out against their inadequate performance in some sectors”, said Dr. Josias.
Read the full report: Shattered Lives