Women Enjoy Punishment: Attitudes and Experiences of Gender-Based Violence

From the Introduction

The new South African government has pledged to ensure women a full and equal role in every aspect of the economy and society. Yet South African women continue to face extraordinarily high levels of violence. Physical abuse and rape are the forms of such violence which have been most clearly described in South Africa. A large community-based study of violence against women, with a random sample of 1306 woman respondents from three provinces, produced provincial estimates of the prevalence of having been subject to physical violence by a current or ex-partner of between 19-28% (Jewkes et al., in press). Moreover, research which has asked men about whether they have physically abused women has found corresponding results, and a survey of 1394 randomly selected men in Cape Town found that 41% reporting having physically abused a female partner in 10 years before the study (Abrahams et al. 1999).

In regards to rape, the most recent South African Demographic & Health Survey (DHS) found a national prevalence figure for rape of 7%, with a range of 3-12% between provinces, while prevalence rates in the Three Province Survey (cited above) ranged from 4.5%-7.2%. Moreover, this survey identified an incidence of rape for women 18-49 years of 1300 per 100,000 women. Although it is beyond the scope of this paper to discuss differences in survey methodology and their implications for interpreting results, the methodological and ethical challenges inherent in conducting such research have been raised elsewhere (World Health Organisation, 1999). It is worth noting, however that, due to such challenges, and due to the broader "normalization" of physical and sexual violence within popular understanding (Wood et al., 1998), it is likely that the figures described above represent an under-estimate of the true magnitude of the problem of violence against women in South Africa (Jewkes et al., 2000).

Strategies for addressing such violence face particular challenges in resource-poor rural areas where, for most women, there is little or no access to shelter, counseling services, or the judicial system (Kim, 1999). In this context, the training of primary health care (PHC) nurses may represent a critical opportunity to begin addressing gender-based violence through the health sector. There are currently about 200,000 nurses in South Africa, constituting the largest category of health personnel in both the public and private sectors. Especially in the impoverished and remote rural areas where there is an acute shortage of skilled medical personnel, the health care system continues to rely heavily on the skills of these clinically trained nurses (South African Health Review, 1996).

Internationally, in response to the overwhelming evidence documenting the prevalence of battered women seen in healthcare settings and the severe long- and short-term health consequences of abuse, nursing and other health professionals have begun to re-define domestic violence as a critical and legitimate issue for the health sector (Heise, Ellsberg and Gottemoeller, 1999). It has been pointed out that the health care system is a logical entry point for the identification of many domestic violence survivors who, all too often, become isolated from their work or social situations. Whether they come for emergency treatment, or for the subsequent long-term effects of abuse, or even for routine care for themselves or their children, this is where nurses may be especially well-positioned to act as resources for these women. (Paluzzi and Houde-Quimby, 1996; Campbell et al., 1993). Moreover, although it is known that most women will not disclose violence in their relationship without being asked (often more than once), in a survey conducted for the American Medical Association, 65% of respondents stated that they would disclose violence to their health care provider before others, including clergy, family, and friends (CDC, 1994).

Yet most health care professionals, including nurses, receive little professional training to intervene in cases of domestic violence (Hendricks-Matthews, 1991; CDC, 1989). Numerous studies in a variety of health care settings have indicated that the rates of detection and intervention in cases of domestic abuse have been appallingly low (Helton et al., 1987; Warshaw, 1989; Henderson, 1992; Motsei, 1993). Moreover, when battered women have been identified, they have often been treated insensitively and had their abuse minimised or ignored, with healthcare workers tending to focus on physical injuries while subtly blaming women for their abuse (Campbell et al., 1994; Warshaw, 1989). It is not surprising then, that battered women often consider healthcare professionals to be the least effective source of help among formal support systems (Bendtro and Bowker, 1989; Hoff, 1990).

In order to explore the context of domestic violence in rural South Africa, and to investigate the potential role of PHC nurses in addressing such violence, research was conducted among a class of 38 nurses enrolled in a 12-month residential training program based in Northern Province. This province, one of the poorest provinces in South Africa, is also one of the least urbanised, with 92% of its population living in rural areas. The Health Systems Development Unit (HSDU) a health systems research and development program within the Department of Community Health, University of the Witwatersrand, has been educating nurses to work in the rural communities of South Africa since 1982. The location of this program within a rural research facility provided an ideal opportunity in which to investigate nurses’ attitudes and experiences of gender-based violence and to subsequently pilot and evaluate a focused educational intervention.

The research had both qualitative and quantitative components: First, focus group research was conducted with the 38 nurses (29 women, 9 men) exploring their attitudes to and experiences of gender-based violence - both as health care workers and as members of their communities. This was followed by an educational intervention in which a one-week intensive gender violence training module was incorporated into the nurses’ Reproductive Health curriculum. The training module was developed and implemented in partnership with a local domestic violence NGO, and addressed needs and priorities previously identified during the focus group research. The training intervention was then evaluated using a structured questionnaire.

This paper describes the nurses' attitudes and beliefs regarding gender-based violence, as well as their experiences of such abuse - both as professionals, and as members of their families and communities. It then situates these observations within emerging international efforts to raise awareness and capacity to address domestic violence within the nursing profession. Finally, in light of these findings, this paper raises key questions and concerns which need to be examined within emerging strategies which envision health care workers as one means of addressing violence against women in South Africa.