According to a recently published Lancet Psychiatry report, intimate partner violence (IPV) is a public mental health issue that requires collective societal change to tackle it effectively. The report, titled The Lancet Psychiatry Commission on Intimate Partner Violence and mental Health: Advancing Mental Health Services, Research and Policy, is one of the largest ever global inquiries into IPV and also included estimates for South Africa.
The report found that IPV is the most common form of violence worldwide, including in South Africa, and that IPV contributes substantially to the global burden of mental health problems.
While the relationship between IPV and mental illness is complex, the authors are clear that it is women and girls who overwhelmingly bear the burden of these experiences. A root cause of this, they say, is gender inequality, something that manifests itself at all levels of society. They found that women and girls living in societies that are most unequal in terms of gender relations are at the highest risk of experiencing IPV, especially where violence against women is an accepted norm.
The authors suggest that societal norms that promote violence are a key issue that needs to be addressed. Men's endorsement of sexist, superior, or sexually hostile attitudes can all be predictors of someone who is likely to commit IPV, while women might be expected to tolerate violence against them.
What is the situation in South Africa?
Worldwide 27% of women and girls aged 15 and older have either experienced physical or sexual intimate partner violence (IPV), but in South Africa, the figure is a staggering third or even up to 50%.
Professor Soraya Seedat, from Stellenbosch University and the South African Research Chair in Post-traumatic Stress Disorder who also co-directs the South African Medical Research Council's (SAMRC) Unit on Anxiety and Stress Disorders, was one of the co-authors of the report.
Responding to the question of whether IPV is getting worse in South Africa, Seedat says, "To some extent we became stuck. There have been pockets of progress but it is difficult to see them because this is such an endemic problem. It is entrenched. It is so common. It digs deep into the social fabric because it is so intertwined with all the other societal problems we have.
"It does require more than just a village to reduce the numbers. If we think about the actual number of people who are affected by IPV... We don't work in a cohesive, in [an] integrated way to reduce the numbers with all sectors. There has been a siloed approach."
She adds that South Africa is one of the top five countries regarding femicide as well, and this means we have a much bigger problem to solve than most countries. "Violence has become normalised, which is not true for many countries around the world." Seedat says poverty is one of the many drivers of IPV but is not the only factor. "We (South Africans) are aggressive and easily provoked, and IPV occurs in all social-economic groups."
Seedat says the figures that are available for South Africa indicate one in three women and teenage girls experience sexual violence and one in two physical violence. "These rates are very high, but one needs to think of it as occurring at any time during their lifetime. It can occur in a current relationship or the perpetrator could be a former partner."
The true national scope of IPV is hard to quantify. She refers to a study published in BMC Public Health that found that the odds of reporting experiences of IPV were lower among adolescent girls and young women (up to the age of 24) in rural informal/tribal areas than urban areas. Other studies elsewhere in Africa, however, have shown that disadvantaged urban settings can also "exacerbate underlying gender-based power disparities, with young women subject to intensive gender-based harassment and a pervasive threat of sexual and physical violence".
Different types of violence
It is a wide range of violence which is inflicted including sexual, physical, emotional, and economic - the latter two are less tangible and researched. "We know it is very rare for one form of violence to occur without another form, these forms of violence go hand in hand," says Seedat. The result is psychological distress which is often shared by the children.
The impact of emotional abuse and how it happens is often overlooked. One woman was quoted in the report saying:
"Through my partner's accusation of mental illness, he made me understand that no one would believe me regarding his abuse because society reduces people with mental illnesses as disconnected from the collective reality. I feared that if I shared my experience of abuse, I would be automatically discredited and disbelieved on the grounds of poor mental health, so I kept quiet. I didn't want to trade the gaslighting of my partner for the gaslighting of a more powerful system, the psychiatric system, where whatever I said would be used as proof of me lacking mental capacity. He could only weaponise mental illness because of the stigma attached to it. It worked. It was as powerful a tactic as his physical abuse."
The Commission noted in the report that people experiencing mental health problems often require the help of professional services to deal with their illness. While this can be the first step towards recovery for many, the Commission finds that many survivors of IPV find interacting with these services to be harmful and re-traumatising.
'a perfect storm of IPV drivers'
Professor Rachel Jewkes, an Executive Scientist at the SAMRC and Secretary of the Sexual Violence Research Initiative, wrote a comment for the Lancet Psychiatry Commission report. She says poverty is very strongly associated with IPV and very poor urban areas such as informal settlements have the highest prevalence.
"We have to address our very patriarchal gender relations and the stagnation of the economy and poverty. We also have to reduce the exposure of children to childhood trauma - both witnessing abuse and their own abuse and neglect - as these drives the next generation of IPV," she told Spotlight.
"We also have very huge problems with alcohol abuse which fuels severe IPV and growing drug use problems. We need as a nation to still heal from the past and get over the severe mental health problems that so many people carry, with anger issues and impairment of trust as these also drive IPV. South Africa almost has a perfect storm of IPV drivers and so unpacking them will take a long time," says Jewkes.
Incremental improvements
Jewkes says there have been incremental improvements in the country over the last 20 years. "Over this time the knowledge that lay- and psychiatric nurse-delivered mental health care can be very effective has grown and so we are positioned for task shifting to more feasible service provision - given the scarcity of psychologists and psychiatrists. But the health service over the last decade has reached increasing depths of dysfunction and that undermines progress in the know-how. I don't think stigma is such a problem with IPV, it's more a problem with rape, but service provision is the overwhelming problem."
Professor Louise Howard the Commission's lead author and a professor in Women's Mental Health at King's College London says, "There is a distinct lack of training offered to mental health professionals like myself. I am a practising psychiatrist. As a medical student, a trainee, and even when I started practising in general adult psychiatry, I was never taught about the effects of domestic violence.
"Given how prevalent this is among service users, this represents a desperate oversight that urgently needs to be addressed," she says.
What can South Africa do?
Seedat thinks two strategies can make huge inroads to ultimately reduce the incidence of IPV.
"We need a prevention and intervention strategy - on a national level," she says. With relatively little cost, Seedat argues, the country can have a prevention strategy in the school curriculum that "very aggressively deals with education and awareness about IPV". "But it is important that this curriculum is formulated in a way that it has an impact from primary school level onwards. Children should be taught about respectful relationships and gender equality via modelling. It needs to be driven by experts in the field. It needs to be embedded and entrenched - like a golden thread through schooling. Another golden opportunity," Seedat says, "is to teach and tutor all healthcare workers about gender-based violence and IPV because it is the most common form of violence."
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According to Seedat, it is important to teach healthcare workers how to ask healthcare users about IPV. "You should be asking about it but this requires skill and you need to know what to do about the information you receive. Listen to the patient and handle it in a respectful way, and be careful not to re-traumatise the patient or to stigmatise."
Jewkes says the ideal would be to have much more accessible mental healthcare services. She says making alcohol less accessible, massive job creation, and gender transformative programming are all important. What will also help is to fix maintenance issues that will enable women to leave violent men and ensure that their children are financially supported.
Types of IPV:
Physical violence: slapping, hitting, kicking, beating, and choking
Sexual violence: sexual contact and behaviour that occurs without explicit consent, including rape, attempted rape, sexual touching, and forcing a person to perform sexual acts
Emotional (psychological) abuse: insults, belittling, humiliation, intimidation, threats to harm, and threats to take away children
Controlling behaviours: acts designed to make a person subordinate or dependent, including isolating a person from family and friends, monitoring a person's movements, and restricting a person's access to financial resources, employment, education, or health care
Coercive behaviours: a continuing act (or pattern of acts) of assault, threats, humiliation, intimidation, or other abuse used to harm, punish, or frighten a person.
