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. 2020 May 5;27(6):925–938. doi: 10.1080/13218719.2020.1751336

Demographic, clinical and forensic characteristics of alleged offenders referred to West End Specialised Hospital, Kimberley, South Africa

Nathaniel Lehlohonolo Mosotho a,✉, Mpho Lesego Bantobetse a, Gina Joubert b, Helene Engela le Roux a
PMCID: PMC8158243  PMID: 34104064

Abstract

The study investigated demographic, clinical and forensic characteristics of alleged offenders referred for forensic assessment. A data collection form was used to gather information from 155 offenders' clinical records. The subjects were mainly young males, aged between 18 and 35 years, with low educational levels and high unemployment rate. The most common diagnoses were substance-related and addictive disorders, and schizophrenia spectrum and other psychotic disorders. A sizeable number of offenders were diagnosed with an intellectual disability. The comorbidity of other medical conditions such as epilepsy and HIV/AIDS was also noteworthy. In total, 55.5% of the offenders were found competent to stand trial, and 46.5% were declared criminally responsible. Offenders presenting with schizophrenia and intellectual disabilities were often declared incompetent to stand trial and were generally not responsible for alleged crimes. There was association between adjudicative competence and criminal responsibility. The results highlight effect of substances on mental illness and crime.

Key words: clinical, competency, criminal responsibility, demographic, forensic, law, mental health, offenders

Introduction

Forensic psychiatry and forensic psychology examine and evaluate the link between mental health and criminality, alongside the diagnosis and treatment of criminals with poor mental health (Neal, 2018; Samuels, 2018). Consequently, the demographic, clinical and forensic data of offenders referred to forensic units for assessment are very important. This study analysed the demographic, clinical and forensic characteristics of alleged offenders referred for evaluation of fitness to stand trial and criminal responsibility, including with regard to age, gender, marital status, race, level of education, employment status, mental health status and criminal behaviour (Khoshnood & Fritz, 2017). Such characteristics have been studied widely in different fields of mental health. The literature indicates that the risk factors for criminal behaviour are being male (Forrester, Samele, Slade, Craig, & Valmaggia, 2017), impaired judgement regarding illness, being single, longer illness duration and associated substance abuse (Ghoreishi et al., 2015). Karsten, de Vogel, and Lancel (2016) note that the number of females in criminal justice systems is increasing across the globe. This means that women with mental health disturbances are prone to committing crimes in the same way as their male counterparts, especially against those in close proximity, such as intimate partners and small children. Indeed, in South Africa, where this study was conducted, a significant number of women have been admitted to various forensic settings.

Offenders suffering from psychiatric disorders pose a challenge to mental health service providers because of the complexity of their combination of mental illness and criminal behaviour (Krona et al., 2017). Individuals who manifest serious mental disorders have diminished capacity to differentiate between right and wrong (Gorgulu, Kucuk, & Cetinkaya, 2015). Schizophrenia is reportedly one of the most commonly diagnosed mental disorders in forensic institutions. The risk factors for this include, among others, undesirable progression and poor prognosis for the disease itself. Baird et al. (2018) explain that active symptoms of psychosis are risk factors for suicide and homicide among sufferers, generally causing them to remain in mental health institutions for longer. Other risk factors for the development of criminal behaviour among psychiatric patients are comorbidity of substance abuse and certain personality traits (Pickard & Fazel, 2013).

Individuals presenting with intellectual disability are also often referred by courts of law for forensic evaluation. In addition, it is important to recognise that the presence of intellectual disability is quite significant, as moderate to severe levels of intellectual functioning can affect an individual’s capacity to participate in legal proceedings in a meaningful manner (White, Batchelor, Pulman, & Howard, 2015). Jones (2007) notes that the majority of people with intellectual disabilities are law-abiding citizens, with the few individuals who display violent and criminal behavioural patterns representing an exception. Another view is that people with an intellectual disability are more susceptible to becoming simultaneously both perpetrators and victims of crime (Nixon, Thomas, Daffern, & Ogloff, 2017).

In Sweden, decisions regarding the discharge of forensic patients are governed by law and not a multi-professional team. The multidisciplinary team carries out two major roles simultaneously: protecting society from the patient’s mental illness and working on the general rehabilitation of the forensic psychiatric patient in order to integrate him or her back into the community (Kottorp, Heuchemer, Petersson Lie, & Gumpert, 2013). The Swedish Penal Code states that should an individual commit a crime owing to the impact of a severe mental disorder, he or she should be subjected to compulsory psychiatric care with or without a court order. Severe mental disorder is a judicial construct, not a psychiatric term (Sygel et al., 2017). It deals with evidence of the presence of a severe mental disorder that is likely to influence the offender’s conduct. Cai et al. (2014) explain that in China, criminal responsibility is classified into three categories: criminally responsible, diminished criminal responsibility and insanity.

In South Africa, should there be any doubt at any stage of the court proceedings concerning the mental status of the alleged offender, or should the alleged offender display any signs of mental and/or behavioural abnormalities, the offender is usually referred under Sections 77, 78 and 79 of the Criminal Procedure Act no. 51 of 1977. A request for referral may be made by the presiding judge, the defence attorney or the prosecutor. This legislation does not provide a specific definition of mental illness but the term is defined in the Mental Health Care Act no. 17 of 2002, which is not binding as far as criminal proceedings are concerned (Department of Justice & Constitutional Development, 1997). The accused is often referred for a forensic mental health examination under the above-mentioned legislation. Nevertheless, its provisions address distinct issues (Swanepoel, 2015). Different aspects of and periods in the accused’s life are considered in each of the sections and should be examined independently. The significance of Section 77 is how it relates to whether the alleged offender has the capacity to participate meaningfully in legal proceedings. This section focuses on the current mental health status of the accused (Pillay, 2014). Section 78 states that a person who commits an act or makes an omission that constitutes an offence and who at the time of such a commission or omission suffers from a mental illness or mental deficit that makes him/her incapable of appreciating the wrongfulness of his/her act or omission or of acting in accordance with an appreciation of the wrongfulness of his/her act or omission cannot be held criminally responsible for such an act or alleged offence (Mosotho, Timile, & Joubert, 2017). According to Section 79 of the same act, the report of the enquiry should include the following details: description of the nature of the enquiry, diagnosis of the mental condition of the accused and the findings in terms of Sections 77 and/or 78. In cases where the findings of different examiners are not unanimous, each examiner will provide his or her findings (Barrett et al., 2007). The examiner should also be aware that the content of the report will be used as evidence in court and that statements made by the accused during the relevant enquiry cannot be admissible during court proceedings, except for the purpose of determining the mental condition of the accused.

It is against this background that the researchers decided to conduct this study whose aim was to investigate the socio-demographic, clinical and forensic characteristics of alleged offenders who were referred for forensic evaluation at the West End Specialised Hospital (WESH) between 1 April 2008 and 31 March 2016 in accordance with Sections 77, 78 and 79 of the Criminal Procedure Act no. 51 of 1977.

Method

Study design and data collection

The WESH in Kimberley, Northern Cape, South Africa, was selected as the geographical location for this research. The Northern Cape is geographically the largest province in South Africa. However, it is also the least populated province in the Republic, with approximately one million inhabitants (Statistics South Africa, 2017). The WESH is the only public mental health institution in Kimberley. This institution is also designated to provide forensic mental health services effective from 1 April 2008 to the present.

A cross-sectional retrospective and descriptive study was conducted. The researchers used a consecutive method of sampling, creating a sample that was an excellent representation of the entire population because it included all accessible subjects (Ehrlich & Joubert, 2014). Consecutive sampling – as a form of non-probability sampling – was more purposeful and strategic for this kind of research than its convenience counterpart (Patton, 2002). In a consecutive sampling method, biases are minimised, because every potentially targeted participant has a 100% chance of being included in the study (Yusen & Littenburg, 2005). The advantage of this technique over random sampling is that it is not excessively wide, instead being very relevant and economical for this type of study. Permission to conduct the investigation was obtained from the management, research and ethics committee of the Department of Health, Northern Cape. The study was approved by the Health Sciences Research Ethics Committee at the University of the Free State. Informed written consent was not necessary, as no direct contact was made with the study sample.

The data consisted of information/records retrieved from the clinical files of 155 alleged offenders. These offenders were referred for assessment of both competency to stand trial and criminal responsibility. The alleged offenders were identified through the forensic observation admission register, and the files were retrieved from the WESH forensic observation clinical records cabinet. A subject identification sheet was used to prevent duplication.

Measures

A data collection form was developed for the purposes of this study to collect data from the alleged offenders’ clinical records. The collected information included demographic data, social circumstances, clinical information (including clinical diagnoses where applicable), types of crimes committed by the alleged offenders and forensic assessment results. It is important to mention that this data collection form has also been used in previous published studies.

Data analysis

The statistical and descriptive analyses of the demographic, clinical and forensic variables were performed by the researchers. The results were summarised, grouped and presented as frequencies, percentages and standard deviations.

Results

The socio-demographic characteristics of the 155 alleged offenders, measured at the same time as the index offences, are presented in Table 1.

Table 1.

Demographic characteristics of the offenders.

  Frequency %
Age (years)    
 18–25 54 34.8
 26–35 60 38.7
 36–50 32 20.7
 51–65 9 5.8
Sex    
 Male 149 96.1
 Female 6 3.9
Marital status    
 Single 141 91.0
 Married 7 4.5
 Widowed 4 2.6
 Divorced 3 1.9
District    
 Frances Baardt 63 40.7
 Siyanda 39 25.2
 Namaqualand 26 16.8
 Pixley ka Seeme 21 13.6
 John Taolo Gaetsiwe 6 3.9
Level of education    
 None 14 9.2
 Grades 1–7 75 49.0
 Grade 8 10 6.5
 Grades 9–11 32 20.9
 Grade 12 18 11.8
 Diploma 2 1.3
 Degree 2 1.3
Employment status    
 Unemployed 59 38.3
 Informally employed 36 23.4
 Formally employed 10 6.5
Self-employed    
 Other sources of income 3 2.0
 Social grant 43 27.9
 Family 23 14.9
Living circumstances    
 Family 144 93.5
 Alone 7 4.6
 Homeless 2 1.3
 Non-family 1 0.7
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The majority (73.5%) of the study subjects were aged between 18 and 35 years, 96.1% were male, and almost 96% were not married. There are five districts in the Northern Cape: Frances Baardt, John Taolo Gaetsiwe, Pixley ka Seeme, Namaqualnd and Siyanda. Forty-one per cent (41%) of the sample came from Frances Baardt, the most populated and urbanised region of the Northern Cape. The province’s capital city (Kimberley) is situated in this district. The other districts are mostly located in rural parts of the province, which covers a large portion of the Kalahari Desert and Little Karoo. The main economic activities are agricultural production (specialising in free-range livestock) and the mining industry. Just over 6% of the accused were formally employed before incarceration. Less than 50% of the alleged offenders had obtained a primary school education, while less than 3% were in possession of tertiary education qualifications. Nearly 94% of the alleged offenders were living with their family members and/or relatives. The clinical diagnoses are provided in Table 2.

Table 2.

Clinical diagnoses.

Diagnosis Frequency % Comorbidity rate(%)
Substance-related & addictive disorders 67 43.2 70.1
Schizophrenia spectrum and other psychotic disorders 50 32.2 50.0
Intellectual disability 33 21.3 42.4
Borderline intellectual functioning 18 11.6 50.0
Antisocial personality disorders 14 9.0 85.7
Bipolar and related disorders 10 6.5 60.0
No psychiatric diagnosis 17 11.0 —
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Note: N = 155. Some offenders were diagnosed with more than one condition.

The largest portion of the research population was diagnosed with substance-related and addictive disorders, followed by schizophrenia spectrum and other psychotic disorders. Intellectual disability was the third most prevalent mental disorder in this research population. It was diagnosed by means of a psychiatric interview (clinical picture) conducted by a psychiatrist and via the administration of standardised psychometric tests by a clinical psychologist. Historically, intellectual disability has been defined as a significant intellectual impairment, measured by an IQ of under 70 (Hellenbach, Karatzias, & Brown, 2017) together with impaired adaptive behaviour or social functioning (McBrien, 2003). Different degrees of intellectual disability (such as mild, moderate, severe and profound) are defined on the basis of adaptive functioning rather than IQ scores, because it is adaptive functioning that determines the level of support required (American Psychiatric Association, 2013).

In all diagnostic categories except intellectual disability, at least 50% of alleged offenders had comorbid diagnoses. For individuals with substance-related and addictive disorders, the main comorbid diagnosis was schizophrenia spectrum and other psychotic disorders (28.4%). For patients with schizophrenia spectrum and other psychotic disorders, the main comorbid diagnosis was substance-related and addictive disorders (38.0%). Over 40% of the alleged offenders were under the influence of substances during the commission of their crimes. The most commonly used substance was alcohol (63%), followed by cannabis (41%). Moreover, certain individuals had a history of polysubstance abuse. After thorough forensic mental health evaluation, it was found that 11% of those offenders did not manifest any psychiatric disorder (diagnosis).

Computed tomography scans were administered by a neurologist on 148 of the offenders, of whom 11% had suffered some sort of brain injury. The results of this neuroimaging examination are displayed in Table 3. A total of 18.7% of the study population were diagnosed with epilepsy.

Table 3.

Location of lesions.

Structure Frequency %
No abnormalities 124 83.8
Bone structures 8 5.4
Parietal 7 4.7
General cerebral atrophy 5 3.4
Frontal 4 2.7
Occipital 3 2.0
Cerebellum 3 2.0
Basal ganglia 3 2.0
Temporal 2 1.4
Frontal sinus polyp 1 0.7
Absent corpus callosum 1 0.7
Posterior cranial fossa 1 0.7
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Note: N = 148.

It was unclear whether the presence of some lesions in the brain was connected to the occurrence of epilepsy, as computed tomography scans only show the structure, not the function. Furthermore, there was no information on whether the brain lesions were congenital or acquired. The prevalence of HIV/AIDS among the participants was reported to be around 5%.

The majority of the alleged offenders with psychiatric diagnoses were aged between 26 and 35 years, followed by those aged between 18 and 25 years; the smallest group of those diagnosed with psychiatric diagnoses were aged between 51 and 65 years. All of the offenders diagnosed with schizophrenia spectrum and other psychotic disorders, antisocial personality disorder, intellectual disabilities and borderline intellectual functioning were male. The alleged crimes committed are displayed in Table 4.

Table 4.

Crimes committed by the alleged offenders.

Crimes Frequency %
Crimes against human beings    
 Rape 69 44.5
 Murder 41 26.5
 Attempted murder 18 11.6
 Assault 15 9.7
 Attempted rape 3 1.9
 Indecent assault 3 1.9
 Pointing a firearm 2 1.3
 Hijacking 1 0.7
 Kidnapping 1 0.7
 Intimidation/extortion 1 0.7
 Domestic violence 1 0.7
 Crimen injuria 1 0.7
Crimes against property    
 House breakings 13 8.4
 Theft 10 6.5
 Malicious damage to property 6 3.9
 Arson 1 0.7
Drug offences    
 Possession of illegal drugs 1 0.7
 Distribution of illegal drugs 1 0.7
Others    
 Contravention of court order 3 1.9
 Fraud 1 0.7
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Note: N = 155.

Rape was the most common crime committed by the alleged offenders, followed by murder and attempted murder. Assault with intent to cause gross bodily harm was also common. Other crimes recorded were house breaking and theft. Crimen injuria1 was committed by less than 1% of the study population. It is important to note that some of the offenders were accused of committing more than one crime at the same time.

The decisions of a forensic multi-professional team on the competency of the alleged offender to stand trial are shown in Figure 1.

Figure 1.

Figure 1.

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The multi-professional teams’ decisions on competency to stand trial.

A notable percentage (55.5%) of the research subjects were found to be competent to stand trial. The associations between psychiatric diagnoses and competency to stand trial were measured. Primarily, individuals presenting with schizophrenia (62%) and those diagnosed with an intellectual disability (60%) were declared not competent to stand trial, whereas all other diagnostic groups were often considered fit to stand trial.

The results of the criminal responsibility evaluations for the alleged offenders referred for forensic evaluation are presented in Figure 2.

Figure 2.

Figure 2.

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The multi-professional teams’ decisions on criminal responsibility.

As seen in Figure 2, a marked portion of the research population (46.5%) was declared criminally responsible for the alleged crimes, with the exceptions of those diagnosed with schizophrenia (of whom 47.9% were considered not criminally responsible) and those diagnosed with an intellectual disability (of whom 24.2% were considered not criminally responsible). Individuals who were competent to stand trial were generally found to be responsible for their crimes (72.1%), whereas just 49.1% of those who were incompetent were found to be not responsible. A noteworthy portion (60%) of offenders who were fit to stand trial with assistance had a diminished criminal responsibility (Table 5).

Table 5.

Competency to stand trial and criminal responsibility.

  Criminally responsible Not criminally responsible Diminished criminal responsibility Total
Competent to stand trial 62 8 16 86
Incompetent to stand trial 7 28 22 57
Competent to stand trial with assistance 3 1 6 10
Total 72 37 44 153
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Discussion

The study’s findings indicate that young males are more likely to commit crimes than their female counterparts. The results are thus consistent with those of other authors: female offenders are less common than male offenders (Sygel et al., 2017). De Vogel and Nicholls (2016) go further, noting that females are a minority in forensic mental health populations worldwide. Possible reasons for this disparity are that women tend to have superior premorbid functioning, good prognoses and levels of social adjustment and favourable courses of schizophrenia relative to their male counterparts (Thara & Kamath, 2015).

Factors associated with the prognosis of mental disorders, such as social support systems, social isolation, marital status and comorbidity of substance abuse, were also considered. It is concerning that the vast majority of the alleged offenders were not married, because healthy marriage can serve as a form of social support that is essential for a good course and prognosis in mental illness as well as for compliance with treatment. Indeed, the literature shows that marriage is a protective factor against violence in psychiatric patients (Elsayed, Al-Zahrani, & Rashad, 2010).

A total of 94% of the research subjects were living with their family members. The very low employment rate of the participants was not in agreement with South African employment rates, as tabulated by Statistics South Africa for the last quarter of 2016. According to Statistics South Africa, approximately 27% of South Africans who were fit to work were unemployed (Statistics South Africa, 2017). This figure is 2% higher than what was reported in 2015. The official unemployment rate in the Northern Cape, where this study was conducted, is 32%. More than 30% of the sample were economically and financially dependent on social grants and the income of another family member(s) with whom they were staying. Educational level and a lack of essential skills for the labour market might constitute contributing factors behind the research sample’s high unemployment rate.

Substance-related and addictive disorders dominated the offenders’ clinical diagnoses. The high incidence of substance use/abuse among the offenders is worrying because it may have a negative impact on the course and the prognosis of the illness. Other researchers have noted that the comorbidity of mental illnesses with substance abuse leads to a high risk of crime and violence (Ogloff, Talevski, Lemphers, Wood, & Simmons, 2015). An alternative perspective is that mental illnesses and criminality are not associated with one another (Varshney, Mahapatra, Krishnan, Gupta, & Deb, 2016). Certainly, there is an exaggerated public perception that people suffering from mental illness are violent and dangerous (Markowitz, 2011). Wessely (1997) and Elbogen and Johnson (2009) have emphasised that mental illness itself is not a significant cause of crime. Nevertheless, research has shown that the link between people presenting with severe mental illness and violence within 12 months of onset is statistically significant but moderate. However, the relationship between severe mental illness and violent behaviour is exacerbated where there is comorbidity of substance abuse (Van Dorn, Volavka, & Johnson, 2012). It has also been reported that individuals diagnosed with schizophrenia and other psychotic disorders are more prone to committing violent criminal acts than the general population (Fazel, Långström, Hjern, Grann, & Lichtenstein, 2009; Penney, Morgan, & Simpson, 2016; Witt, Lichtenstein, & Fazel, 2015). Nonetheless, the view of the researchers is that this well-documented relationship between mental health and criminal acts should not be used to reinforce discrimination against and stigma towards people suffering from mental disorders.

Regarding intellectual levels of functioning, a marked portion of the alleged offenders were diagnosed with either borderline intellectual functioning or mild intellectual disabilities. This finding is similar to what has been reported by other researchers: that these individuals are sometimes highly represented in the criminal justice system, depending on the part of the world in which they live (Vanny, Levy, & Hayes, 2008). A marked portion of this population is in correctional service centres and prisons (Raina, Arenovich, Jones, & Lunsky, 2013), owing to the fact that each country has its own forensic practices and laws (Riches, Parmenter, Wiese, & Stancliffe, 2006). The assessment of the demographics of the various diagnosis groups revealed that males predominated in all diagnoses, including antisocial personality disorder and intellectual disabilities. Accordingly, numerous authors have suggested that antisocial personality disorder and intellectual disabilities are more common in males than in females (American Psychiatric Association, 2013; Ng, Sandberg, & Ahlström, 2015; Soltan, Khosravi, & Salehiniya, 2015).

The alleged offenders were mainly accused of rape, murder, attempted murder and assault with intent to cause gross bodily harm. Crimen injuria was one of the least common crimes committed by the accused. The crime is used in the prosecution of certain instances of road rage, stalking, racially offensive language, emotional or psychological abuse and sexual offences against children (Clark, 2004; Hanti, 2006; Van Niekerk, 2003).

The associations between clinical diagnoses and alleged crimes were also assessed. Alleged offenders suffering from schizophrenia and other psychotic disorders were accused of committing more crimes against human beings than crimes against property. Notably, almost 67% of the alleged offenders diagnosed with an intellectual disability were accused of rape. The link between a diagnosis of an intellectual disability and an accusation of rape seen in this study concurs with Sakdalan and Egan (2014), who have reported that offenders diagnosed with an intellectual disability are more likely to be charged with sex-related offences. Concerning theft, those who were diagnosed with schizophrenia spectrum and antisocial personality disorder were almost equally represented at 14% and 14.3%, respectively. In brief, the schizophrenia spectrum group was most frequently represented in all crimes.

Alleged offenders with schizophrenia were mainly found to be unfit to stand trial, meaning that they could not follow court proceedings or provide appropriate and relevant instructions to their legal teams. The evaluation results also indicated that their mental status during the legal proceedings was not sufficiently sound to proceed with criminal charges. This argument is supported by Chauhan, Warren, Kois, and Wellbeloved-Stone (2015) and Kois, Pearson, Chauhan, Goni, and Saraydarian (2013), who have reported that offenders diagnosed with serious mental disorders are less likely to be found competent to stand trial.

It is important to note that the individuals who were found to have diminished criminal responsibility were more numerous than those who were found to not be criminally responsible. The concept of diminished criminal responsibility has been analysed and interpreted in various ways across the globe. Stevens (2016) explains that there is no clear-cut definition of diminished criminal responsibility in South African law. The concept is applied when a court of law concludes that the offender was criminally responsible, but lacked the capacity to differentiate between right and wrong owing to mental illness and/or mental deficit. Finally, the researchers argue that the present study is significant not only because it contributes important academic data to a field that has been largely neglected in the Northern Cape of South Africa, but also because it provides information on the demographic, clinical and forensic characteristics of alleged offenders referred for forensic evaluation.

Conclusion

The majority of the subjects in this study were young single males. Schizophrenia spectrum and other psychotic disorders were found to be the second most common diagnoses after substance-related and addictive disorders within this study population. It is of considerable concern that a large number of the alleged offenders were reportedly under the influence of substances on the day of their offences. According to the clinical records, the prevalence of other medical conditions such as epilepsy and HIV/AIDS was also noteworthy. One of the most worrying findings of this study was that crimes were more commonly directed towards human beings than towards property. There was a strong association between competency to stand trial and criminal responsibility. The alleged offenders who were diagnosed with schizophrenia spectrum and other psychotic disorders and intellectual disabilities were regularly found to be not competent to stand trial and were often not responsible for their alleged crimes.

The study confirms the reported link between mental illness, criminality and violent behaviour, exacerbated by a high rate of substance abuse among offenders. Although the investigation has presented important findings, the results should be interpreted with caution, as the small sample size and restricted area of research may affect the generalisation of the results. It is also recommended that the multi-professional team based at the WESH be frequently trained on the Criminal Procedure Act no. 51 of 1977, Sections 77, 78 and 79, as well as the Mental Health Care Act of South Africa. This suggestion is motivated by discrepancies found in the clinical notes, conclusions and recommendations on the aspects of competency to stand trial and criminal responsibility. It is recommended that a multi-professional team approach consistently be followed. Health professions such as psychiatric nursing, occupational therapy and social work should also be part of multi-professional teams. The roles of these professionals in the forensic assessment of offenders are of the utmost importance.

Note

1

Crimen injuria is a crime under South African common law, defined as the act of unlawfully, intentionally and seriously impairing the dignity of another (Clark, 2004).

Ethical standards

Declaration of conflicts of interest

Nathaniel Lehlohonolo Mosotho has declared no conflicts of interest

Mpho Lesego Bantobetse has declared no conflicts of interest

Gina Joubert has declared no conflicts of interest

Helene Engela le Roux has declared no conflicts of interest

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

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