Perceptions of gender-based violence among South African youth: implications for health promotion interventions

Abstract

Gender-based violence is a widespread problem in South Africa. Past structural inequities have created a climate conducive to violence against women. As an initial step toward developing a health promotion program, we conducted exploratory formative research to examine the barriers that affect the health and well-being of youth. Fourteen focus groups (nine with girls and five with boys) were conducted with 112 adolescents in a racially mixed community on the outskirts of Cape Town, South Africa. We utilized grounded theory and thematic analysis to examine the data. The impact of poverty, ubiquitous gendered violence, transactional sex and unsafe recreational spaces emerged as the major themes. The experiences of youth were consumed by issues of safety rather than the pursuit of other developmentally appropriate markers. Our findings suggest that health promotion programs should create safe spaces for youth and opportunities to critically question the assumptions and manifestations of a patriarchal society. Furthermore, the findings indicate that there is a strong need for multi-sectorial interventions directed at many levels to prevent gender-based violence.

INTRODUCTION

Globally, violence against women is a significant public health concern. The United Nations defines it as physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty occurring in public or private life. In South Africa, gender-based violence is a widespread problem of substantial concern. Social and economic conditions in the South African townships, exacerbated by a history of apartheid, have created a climate for violence against females. For a country not at war, South Africa has some of the worst statistics regarding gender-based violence (Moffett, 2006). As of 2006, South Africa ranked at the top internationally for the greatest incidence of reported rape and sexual violence (Britton, 2006). Attitudes about sexuality and gender relations are culturally inscribed. Gender-based violence involves an assertion of ideals about male identity and power, and it reflects major gaps in policies to protect women.

Young people and gender-based violence

Adolescents in South Africa may be at particular risk for complications associated with gender-based violence. Experiencing forced sex at an early age can influence women's sexual behavior in later years (Jewkes, 2000), including having unprotected intercourse (Varga and Makubalo, 1996), thereby exposing themselves to greater risk of sexually transmitted infection and pregnancy. Gender-based violence can have a negative impact on a young woman's ability to negotiate sexual relationships. Interviews with pregnant adolescent Xhosa women revealed that many young women view assault as an expression of love; ‘I fell in love with him because he beat me up’ (Wood and Jewkes, 1997). Non-consensual sexual intercourse is very common among adolescents and is often seen as normal ‘boy’ behavior (Dickson-Tetteh and Ladha, 2000; Jewkes and Abrahams, 2002). Myths circulate in adolescent communities that abstinence is bad for one's mental health (Armstrong, 1994) and girls risk being socially ostracized if they do not have sex (Wood et al., 1998).

Gender violence is also inextricably linked to other social problems. Violence and insecurity in the post-apartheid era have weakened South African schools, with gangs disrupting education at will (Meier, 2002). Rape and sexual coercion often take place at school with little redress by teachers and administrators (Armstrong, 1994). In fact, teachers are occasionally the perpetrators of such violence. For example, girls have been threatened with school failure for not having sex with a teacher (Jewkes, 2000). In addition, adolescent girls may face economic pressures to allow older men to be their ‘sugar daddies,’ exchanging sex for presents or money for themselves and/or families (Hunter, 2002; Jewkes and Abrahams, 2002).

This research was conducted as part of a larger study designed to explore the socio-cultural factors that relate to the design and development of a cervical cancer prevention program in Cape Town, South Africa (Mosavel et al., 2005). This paper discusses the findings from focus groups with youth in a peri-urban Black and Colored community in Cape Town, South Africa. [Although the Population Registration Act of 1950, which authorized registration by race, was repealed in 1991, the use of these racial categories reflects the historical background of participants, their continued attempts at self-identification and the remaining legacy of apartheid. ‘Black’ refers to indigenous people of South Africa who speak one of the African languages as their native language. ‘Colored’ refers to people considered to be of mixed race, classified as such by the former apartheid government of South Africa.] The aim of the focus groups was to explore the experiences of, and challenges to, youth in low-income contexts that influence health outcomes. From this data, we report on the prevalence of gender-based violence and its importance as a focal point in health promotion programs aimed at youth from communities with a similar profile.

METHODS

The setting

Masidaal (pseudonym used for actual city name) is an urban community with both black and Colored residents located on the outskirts of the city center of Cape Town. We received human subjects approval from the local Department of Education and our university's Institutional Review Board. We established collaborative relationships with the four high schools in this community and recruited the sample from this population. We focused on students in grades 8 through 10 at the request of the local Education Department so as to cause minimum disruption to learners in higher grades.

Participants

Youth participants were randomly selected using class lists at each school. We identified equal numbers of girls and boys from both Black and Colored ethnic groups. All school materials are distributed in English; therefore, we decided to keep the consent and assent forms in English.

Informed consent began with an informational meeting held at each school. Meetings were held after school where we informed eligible participants about the study and invited questions. Of those who attended the informational meetings, 75% returned a signed parental consent. Of that group, 80% of girls and 60% of boys provided written assent.

Focus groups

Focus group questions were designed to be broad-based inquiries into the context of adolescents' well-being and their perceptions of health. Questions were developed in collaboration with a community group and pilot-tested. The questions that we analyzed for purposes of this paper are: (1) ‘What makes it difficult for youth to have fun?’ and (2) ‘What do you think are the health related problems of young people in this community?’ Prompts for this question included ‘What about safety?’ and ‘What about violence?’

Young, local community members of a similar ethnic background were hired, trained and paired with an experienced moderator to co-facilitate the focus groups in an effort to relate better to the participants. We conducted separate groups with boys and girls. All focus group discussions were audio-recorded and transcribed.

Data analysis

The data analysis process was guided by principles of grounded theory (Glaser and Strauss, 1965) and the code structure was developed using a process of inductive reasoning. We conducted manual data analysis where members of the research team separately identified concepts related to what made it difficult for youth to have fun. Two coders analyzed the data. Emerging from the data, coders identified narratives that were repeatedly encountered. Gender-based violence and poverty began to emerge as central themes. Once coders identified these concepts, they inductively identified the categories. Once consensus about the definition and scope of the category was reached, codes were identified. The coders collectively discussed the codes and its conceptual linkages to the categories. We used a constant comparative analysis method to compare the emerging themes across the focus groups (Glaser and Strauss, 1965). Coding discrepancies were resolved by the input of a third coder who reached a decision by reviewing the disputed response as well as the previously defined category.

RESULTS

Demographics

We conducted 14 focus groups (9 with girls and 5 with boys) with 112 students selected from four high schools in Masidaal. The average age was 15 and the majority (68%) of participants was girls. Most participants (74%) were eighth graders, 11% were ninth graders and 15% were tenth graders. Almost half (47%) had lived in the community for five or more years, while 19% had lived there for less than a year. Of the participants, 34% spoke Xhosa at home, 41% spoke Afrikaans and 13% spoke Afrikaans and English. The majority of participants (71%) reported that their fathers lived with them. The average family size was seven. Many participants had members of their extended family living with them, such as aunts, uncles, and grandmothers. About half the participants (51%) reported that at least one of their parents was permanently employed.

In response to the questions regarding what makes it difficult for youth to have fun and the health issues of young people in this community, the major themes that emerged were the impact of poverty, ubiquitous gendered violence, the prevalence of transactional sex and unsafe recreational spaces.

The impact of poverty

Poverty, unemployment and limited choices were frequently recurring themes. Participants reported on how these issues raised challenges at home. One boy stated, ‘I'd say most violence comes from home, maybe there's no food at home for the whole week, there's nothing, the mother doesn't work, the father doesn't work, maybe the mother drinks and the father drinks, nobody cares.’ Participants voiced similar responses regarding unemployment, such as, ‘So most of the people need money … they don't have jobs.’

Participants articulated a clear link between poverty and other social problems. For example, one participant said, ‘Like people are poor, like a person thinks that this could be the way, I must sell my body’ and ‘ … girls say prostitution is easy money.’ Reportedly, selling drugs was another means of earning money, ‘ … Sometimes your family is poor and you see this way of making money, maybe you think, ‘Hey, let me sell drugs or sell pills.’ … you're destroying other people's lives, by selling, but you're doing it so that you can eat.’ Indicating the link between violence and poverty, one boy stated,

You also get gangsters … they like to rob children take their money you know. Like when they have shoes that are like Nike, Adidas, Reebok and that, they like to take their shoes … if you don't want to give them money, then they are almost like- they take out a knife or something like that, and they take the money.

Ubiquitous violence

Two main themes emerged. First, violence was embedded in different social spaces and, second, gendered violence was pervasive, multilayered and linked with other social problems. When we asked girls about what makes it difficult to have fun, girls in different groups provided similar responses. Girls talked of the everyday risk of gender-based violence. For example, ‘Like other children are raped by their parents in their own homes, by their fathers, maybe their fathers tell them, ‘I will give you money, you must never tell anyone.’ … even when she's with her friends, she's always quiet, now she can't talk to her friends, like she'll be killed.’ In another group, ‘They rape children, small children. The mothers have children alone, maybe the daddies they rape the children.’ Notably, none of these participants talked about themselves as having been sexually victimized, but limited themselves to discourse about violence that happens around them. Other comments regarding violence varied from, ‘they [boys] grab your breasts,’ to ‘they force you to have sex,’ or, ‘they throw something in the girls’ drink to rape her.’

In both girl and boy focus groups, frequent observations were made about relationships between genders that reflected complex socio-psychological processes and patriarchal relationships. For example, one girl stated, ‘Most of the time when girls have fun, maybe we are sitting around as a group of girls and then boys come along and maybe then grab one of them and go and rape her.’ On the other hand, boys were more likely to express animosity about girls. In these narratives, girls were the temptress and boys were the victim. Expressing this view, one boy stated, ‘ … like a girl pretend to like a guy, but she wants money from the guy, she doesn't want him.’ Examples of blaming girls include this type of comment, ‘ … when you are looking at the way the girl is dressed, she could even get raped because of the way she's dressed, because she's not dressed to come to school … ’

Transactional sex

Another major theme centered on the exchange of favors performed by girls. These girls are usually in relationships with older boys or young men who are perceived as powerful and attractive. Reportedly, these individuals gain their reputation through acts of bravado, including crime, drug peddling, drug use and violence. For example, ‘Mostly these girls' boyfriends are like bad boys, gangsters.’ Older boys and young men provide girls with luxury items such as cash, clothes, earrings, cigarettes and alcohol. Many participants indicated that ‘resourceful’ males would occasionally provide a girl's parents with food and gifts in exchange for sex with their daughter.

Boys, on the other hand, remarked that girls often exploit boys of similar age for their money, expensive clothes or other material need. Therefore, boys in the focus groups felt they were entitled to receive something in return. One boy explained, ‘Okay, the boy will think okay you like my money, you like my clothes, you always want money from me, and what do I get from you?’ Some girls were said to have ‘sugar daddies’ who were typically older men who provided for some of the young girl's material needs in exchange for sexual favors. One focus group participant talked about the multiple lures and dangers associated with sugar daddies,

… some girls go out with boyfriends who are older than them … maybe he's finished school, and he doesn't understand that you're still at school, and he tells you to stay with him the whole week and you don't go to school … There are many people who go out with boys who are much older than themselves. And a person says ‘its love,’ and the boyfriend thinks I don't love her, I just see a girl and I want one thing, to have sex …

The phenomenon of ‘taxi queens’ provides another example of favor exchange. According to participants, taxi queens are young girls who accompany a male taxi driver for the day. The taxi queen's role is to keep the driver company and allow him to touch her over the course of the day, at the end of which she may be compensated, usually with money.

Jukeboxes

The reference to jukeboxes as an example of an unsafe recreational space and, as a site for fostering opportunities for gender-based violence was repeatedly referenced in the focus groups. ‘Jukeboxes’ refers to a space within a residential home that has been revamped, usually to sell inexpensive liquor with a jukebox available for patrons to play music. Additionally, ‘tuckshops,’ a space within a residential home that has been altered to serve as a convenience store, may also have a jukebox available to customers. Money is inserted into the jukebox which booms music throughout the residential neighborhood. Examples of comments expressing concern for the role of these jukeboxes include, ‘Most of the time it's the jukeboxes, even the teenage pregnancy comes from those jukeboxes, people get raped because they drink and smoke … at the end you will be a victim of the jukeboxes.’ According to some participants, there are more ‘shebeens’ (illegal neighborhood bars) in the community than churches, recreational centers or playgrounds.

DISCUSSION

The broad question as to what makes it difficult for youth in this community to have fun and be healthy resulted in repeated narratives about three overarching, if interrelated, concerns. These were identified as the impact of poverty on the community and youth, unsafe recreational spaces and ubiquitous gender-based violence. The ability of these young people to clearly identify these concerns as impeding their overall well-being suggests that health promotion programs need to use a comprehensive framework within which to provide health education. The complex relationship between the macro and micro levels of concern that emerged from the grounded theory approach suggests that an encompassing theoretical framework, such as the social ecological model, may be useful to understand and address these challenges. Several successful efforts in addressing gender-based violence have utilized the social ecological model (Maciak et al., 1999; Oetzel and Duran, 2004) and the emergent multi-layered manifestations of gender violence in our study suggests the need for multi-sectorial interventions at all levels (Freeman et al., 2006; Seedat et al., 2009). We provide a few suggestions by drawing from our data and scholarship in this area.

The emerging data underscoring the pervasiveness of gender-based violence and its interconnectedness with poverty are consistent with the findings of various other studies conducted in South Africa (Dickson-Tetteh and Ladha, 2000; Jewkes and Abrahams, 2002; Dunkle et al., 2004; Seedat et al., 2009). Participants' narratives identified many of the problems present in low-income neighborhoods. The limited employment opportunities, daily financial struggles in poor households, prevalence of crime, dysfunctional schooling systems, the absence of recreational facilities and the dangers associated with organic recreational spaces, like jukeboxes, were just some of the processes that impacted the well-being of youth. These processes speak to an absence of community cohesion (Sonn and Fisher, 1998; Wolkow and Ferguson, 2001; Cantillon et al., 2003) and results in serious barriers to the health and well-being of youth. More importantly, these barriers prevent them from engaging in developmentally appropriate pursuits. Furthermore, poverty also intersected with patriarchal relationships in a way that had profound consequences for youth. Poverty was one of the key motivators for involvement in transactional sex (Hunter, 2002; Wojcicki, 2002a,b; Sichone, 2006).

From a public health perspective, the health effects of gender-based violence cannot be underestimated. A study conducted in South Africa with women ages 16 to 44 suggests transactional sex not only places women at higher risk for HIV, but it is associated with substance abuse and lower socio-economic status (Dunkle et al., 2004). Adolescent girls who reported abuse from dating partners were at a significantly elevated risk for unhealthy weight control, consideration of or attempts at suicide, and other sexual and health risk behaviors (Silverman et al., 2001). Overall, the greater the number of childhood abuses, the poorer one's health as an adult and the more likely a woman will experience abuse as an adult (Moeller et al., 1993). Female health is considerably impacted by gender-based violence, with multiple effects on adolescent girls that often persists into womanhood. For these reasons, addressing gender-based violence within a health context is critical.

Our findings suggest that the context in which gender-based violence occurs is amidst cultural constructions of love, sex and entitlement to which girls are expected to submit, and highlight the need to critically engage young people about patriarchal gendered relations. South African attempts in this area have been informed by two important currents. It is argued that a change in gender relationships informed by feminism needs to accommodate a shift from ‘power over’ women to ‘power with’ women, and should include work with both genders (Shefer et al., 2008). In a similar vein, Ratele argues that there is a presence of a ruling masculinity in South Africa—a masculinity that seeks to subjugate and promote a rampant sexuality—thus, there is a need to ‘unscrew masculinity’ and replace this ruling paradigm with a new one that promotes gender equality (Ratele, 2006, 2008).

Health programs, especially those that provide a holistic focus, provide a logical starting point for addressing the political and social construction of gendered roles (Andersen et al., 2002). However, it is important that discussions within these programs address the root causes of gender oppression in addition to providing alternative and respectful communication strategies. Programs could, at a minimum, engage young people in a dialogue about gender-based violence, its origins, manifestations and potential impact on overall health and well-being. Actively engaging girls and boys in analyzing their own constructions of each other and critically examining the patriarchal norms fueling gender-based violence could provide useful insights and promote critical thinking—often a necessary precursor to creating attitudinal and behavioral change. Some of these ideas have been incorporated into promising interventions in South Africa. For example, the partnership between Engendered Health and the Planned Parenthood Association of South Africa (PPASA) has actively involved men in dialogue and activism about preventing gender-based violence. They created the Men as Partners (MAP) program and evaluation results indicate that MAP created positive changes in both attitudes and behaviors for many of the men (Peacock and Levack, 2004).

Policy formulation and implementation is vital to addressing gender-based violence. At the policy level, there have been many positive developments in the South African context. The South African Constitution, the Gender Commission and the Domestic Violence Act of 1988 are examples of significant policy attempts to address gender violence. However, the reported incidence of gender violence in this study, as well as in other studies (Freeman et al., 2006; Seedat et al., 2009), points to the need for multiple mechanisms to help realize policy intentions. To help bridge the gap between policy formulation and implementation, a whole host of processes are needed. At the state level, it requires a well-functioning judiciary and police system. At the community level, it requires more social development resources, like shelters and counseling, and a foregrounding of gender rights in areas such as the school curricula. The state focus on gender rights must be complemented by civil society participation to create greater awareness of gender rights.

The emphasis on poverty also suggests the need for poverty reduction and empowerment initiatives at the community level. The impact of poverty suggests the need to address the lack of economic opportunities for people within poorly resourced neighborhoods. Therefore, community development is an important intervention for both alleviating poverty and addressing gender violence. One example is the Urban Renewal Program (URP), which was introduced by the South African Parliament in 1999 (Rauch, 2002). Some of the aims of the various Urban Renewal strategies seek to encourage people to be active in their own development, reduce unemployment, enhance safety and security and create affordable, sustainable housing options. However, URPs were only developed in specific metropolitan nodes of South Africa. Similar efforts to establish URPs could prove to be very beneficial in communities like Masidaal.

The repeated symbolism of the jukeboxes as unsafe spaces in the community signifies the lack of leisure facilities as well as economic opportunities to create legitimate income sources. Engaging jukebox owners and taxi drivers as part of advisory teams in health promotion programs could contribute to raising awareness about the importance of creating safe environments free of gender-based violence (Reissman, 1965). The symbolism of the jukeboxes also speaks to the absence of neighborhood cohesion and the importance of developing social capital to create safe communities. Scholarship consistently points to the relationship between the absence of social capital and outcomes like crime and violence (Kawachi et al., 1997; Emmet, 2003). While the presence of adversity in low-income communities should not be underestimated, studies also point to resilience processes in these communities (Ahmed et al., 2004) which could be utilized for developing social capital. Social capital is crucial for processes like developing informal social controls and facilitating community development and empowerment. One example in the South African context is the partnership between the Medical Research Council (MRC) and University of South Africa (UNISA) Safety and Peace Promotion Research unit and low-income communities. Through this partnership and strategies like research dissemination, communities have been empowered to work towards developing interventions that promote safety in their neighborhoods (UNISA, 2010). For example, designated communities focused on gender violence by undertaking a campaign called 16 days of Activism. In this campaign, the community became responsible for formulating and implementing activities that illuminate the reality of gender violence.

Finally, this study has some limitations which effect the interpretation and generalizability of the data. First, although this was a randomly selected sample from four high schools, the focus group data may not be generalizable to wider populations (Robinson, 1999). Secondly, the research question was centered on the major barriers to health, and gender-based violence happened to emerge organically as being a main concern. Furthermore, while the focus groups provided an ideal forum for participants to talk about issues in the community, we acknowledge that most of what was shared was rooted in their perceptions of what happened to others. Within a group setting, participants are less likely to be open when the focus is on their personal and sensitive experiences (McCaw and Senn, 1998). While the interpretation of these findings should be tempered by knowledge of its limitations, existing evidence of the pervasiveness of gender-based violence within similar communities in South Africa cannot be ignored. Finally, even though this was a randomly selected sample, it is possible that a focus group methodology did not allow us to hear from those most affected by gender-based violence in the community, including taxi queens and abused girls. Such individuals often have good reasons for not stepping forward and sharing their views and experiences, including the fear of being publicly identified and/or ridiculed. Furthermore, we acknowledge that these focus group discussions primarily centered on gender-based violence within the context of heterosexual relationships.

CONCLUSION

Consistent with other scholarship, our findings suggest that the risk factors for violence, as well as other social problems, are inextricably linked. However, the impact of gender violence reported in this study indicates the need to prioritize interventions in this specific area. The proposed interventions identified as best practices are promising and can be incorporated within health programs. However, our findings also point to the complex, multi-layered nature of gender violence. Complementing health promotion efforts at the community level with other systemic interventions, like building social capital and addressing economic inequalities, provides possible pathways to address gender violence.

FUNDING

This study was supported by the National Institutes of Health NCI R25 Prevention Research Educational Postdoctoral Training Program (PI: Laura Siminoff). We received additional funding from the Case Comprehensive Cancer Center, in Cleveland, Ohio.