The gendered context of women charged with violent offences in the forensic psychiatric setting

Background

Women charged with violent offences may be referred by courts for forensic psychiatric assessment to determine whether mental disorder or intellectual disability impacts their fitness to stand trial and/or criminal responsibility. The profile of these women is a poorly researched area in South Africa.

Aim

This study examined the socio-demographic, offence-related, and clinical profile of South African women charged with violent offences referred for forensic assessment.

Setting

Fort England Hospital (FEH), a forensic psychiatric institution in the Eastern Cape.

Methods

The clinical records of 173 women referred by courts for forensic psychiatric evaluation over a 24-year period (1993-2017) to FEH were systematically reviewed.

Results

Most women were single, black mothers with dependent children, who were unemployed and socio-economically impoverished. Many had backgrounds of pre-offence mental illness, alcohol use and alleged abuse. The majority were first-time offenders whose victims were known to them. Most child victims were biological children killed by their mothers. Likely primary motives for violence were related to psychopathology in half of cases, and interpersonal conflict in a third. Forensic assessment most frequently confirmed psychotic disorders and dual diagnoses. Half the cases were fit to stand trial and under half were criminally responsible.

Conclusion

Violent female offending occurs within a gendered context, with high rates of prior trauma, alcohol use and psychosocial distress in perpetrators. An emphasis on gender-sensitive psychosocial interventions is required.

Contribution

This study highlights the nature and context of violent offending by women referred for forensic psychiatric assessment in South Africa.

ICD-11 Paraphilic Disorders: A South African Analysis of Its Utility in the Medico-Legal Context

BACKGROUND

In an effort to improve the clinical utility of the ICD-10, the WHO Working Group on the Classification of Sexual Disorders and Sexual Health recommended a new classification of Paraphilic Disorders in the ICD-11 to replace the ICD-10 section on Disorders of Sexual Preference. The proposed classification may have different implications for different countries.

AIM

To examine South African national laws and policies, within which Paraphilic Disorders are encountered, and to assess the implications of the new classification.

METHOD

A South African working group - representing experts within the disciplines of criminal law, psychiatry, psychology, public health, and criminology - reviewed: (i) national laws affected by reclassification, (ii) current practices in the psycho-legal assessment of sexual offenders, (iii) the implications of the reclassification for assessment and decision-making in forensic practice and other health settings, (iv) specific implications of the reclassification for diagnosis, and (v) implications of the reclassification as it relates to the demographic and sociocultural context of South Africa.

OUTCOMES

As a rule, South African courts do not accept the existence of a Paraphilic Disorder on its own to be sufficient grounds to absolve any defendant from criminal responsibility though defence. Nevertheless, a diagnosis such as coercive sexual sadism disorder runs the risk of medicalization of criminal behavior with inappropriate use to mitigate sentences.

CLINICAL IMPLICATIONS

The ICD-11 approach is clinically useful in emphasizing that a broad range of sexual behavior fall under the rubric of healthy sexual behavior, but also that compulsive sexual behavior can be pathological.

STRENGTHS AND LIMITATIONS

This analysis was conducted by an interdisciplinary expert group, aligning international forensic mental health and national legal constructs in a low-middle income country (LMIC). The analysis is limited by its reliance on expert opinion rather than empirical data.

CONCLUSIONS

It is recommended that the ICD-11 includes a cautionary statement for forensic use, highlighting the fact that the mere inclusion of a diagnosis in the ICD-11 does not necessarily have forensic relevance. Artz L, Swanepoel M, Nagdee M, et al. ICD-11 Paraphilic Disorders: A South African Analysis of Its Utility in the Medico-Legal Context. J Sex Med 2021;18:526-538.

The psycho-social and clinical profile of women referred for psycho-legal evaluation to forensic mental health units in South Africa

BACKGROUND

There is a paucity of research on women offenders in the South African context, particularly those referred for forensic psychiatric observation. Little is known about their life histories, the nature of their offences or the psycho-social contexts that enable, or are antecedents to, women's criminal offending.

AIMS

This research study, the largest of its kind in South Africa, examined the psycho-social contexts within which women offenders referred for psychiatric evaluation come to commit offences. The profiles of both offenders and victims, as well as reasons for referral and forensic mental health outcomes, were investigated.

METHODS

A retrospective record review of 573 cases, spanning a 12-year review period, from six different forensic psychiatric units in South Africa, was conducted.

RESULTS

The findings describe a population of women offenders who come from backgrounds of socio-demographic and socio-economic adversity, with relatively high pre-offence incidences of being victims of abuse themselves, with significant levels of mental ill-health and alcohol abuse permeating their life histories. The majority of index offences which led to court-ordered forensic evaluations were for violent offences against the person, with murder being the single most common index offence in the sample. Most victims of violence were known to the accused. There were also relatively high rates of psychotic and mood-spectrum disorders present, with relatively low rates of personality disorders. The majority of women were deemed to be trial competent and criminally responsible in relation to their index offences.

CONCLUSION

It is recommended that more standardised and gender-sensitive forensic mental health assessment approaches, documentation and reporting be employed throughout the country. Future research should compare male and female offending patterns and forensic mental health profiles.

From victim to perpetrator to survivor: The psycho-social context of South African women offenders

Background

There is a paucity of research on women offenders in the South African context, particularly those referred for forensic psychiatric observation. Little is known about their life histories, the nature of their offences or the psycho-social contexts that enable, or are antecedents to, women’s criminal offending.

Aim

This research study, the largest of its kind in South Africa, examined the psycho-social contexts within which women offenders referred for psychiatric evaluation come to commit offences. The profiles of both offenders and victims, as well as reasons for referral and forensic mental health outcomes, were investigated.

Methods

A retrospective record review of 573 cases, spanning a 12-year review period, from 6 different forensic psychiatric units in South Africa, was conducted.

Results

The findings describe a population of women offenders who come from backgrounds of socio-demographic and socio-economic adversity, with relatively high pre-offence incidences of being victims of abuse themselves, with significant levels of mental illness and alcohol abuse permeating life histories. The majority of index offences which led to court-ordered forensic evaluations were for violent offences against the person, with murder being the single most common index offence in the sample. Most victims of violence were known to the accused. There were also relatively high rates of psychotic and mood-spectrum disorders present, with relatively low rates of personality disorders. The majority of women were deemed to be trial competent and criminally responsible in relation to their index offences.

Conclusion

It is recommended that more standardised and gender-sensitive forensic mental health assessment approaches, documentation and reporting be employed throughout the country. Future research should compare male and female offending patterns and forensic mental health profiles.

Legal duties, professional obligations or notional guidelines? Screening, treatment and referral of domestic violence cases in primary health care settings in South Africa

BACKGROUND

Since 2013, approximately 4400 women have been murdered by their partners in South Africa. This is five times higher than the per capita global average. Domestic violence is known to be cyclical, endemic and frequently involves multiple victims. It also becomes progressively more dangerous over time and may lead to fatalities. In 2012, the Health Professions Council of South Africa released a domestic violence protocol for emergency service providers. This protocol, or screening guidelines, includes assessing future risk to domestic violence, providing physical and psychosocial care, documentation of evidence of abuse and informing patients of their rights and the services available to them. The extent to which these guidelines have been circulated and implemented, particularly by general health care practitioners (HCPs), is unknown.

AIM

We review international treaties to which South Africa is a signatory, as well as national legislation and policies that reinforce the right to care for victims of domestic violence, to delineate the implication of these laws and policies for HCPs.

METHOD

We reviewed literature and analysed national and international legislation and policies.

RESULTS

The 'norms' contained in existing guidelines and currently practiced in an ad hoc manner are not only compatible with existing statutory duties of HCPs but are in fact a natural extension of them.

CONCLUSION

Proactive interventions such as the use of guidelines for working with victims of domestic violence enable suspected cases of domestic violence to be systematically identified, appropriately managed, properly referred, and should be adopted by all South African HCPs.

Sexual violence against children in South Africa: a nationally representative cross-sectional study of prevalence and correlates

BACKGROUND

We aimed to complete a nationally representative study of sexual violence against children in South Africa, and its correlates, since we could identify no other such study.

METHODS

For this nationally representative, cross-sectional study in South Africa, households were selected by use of a multistage sampling frame, stratified by province, urban or rural setting, and race group, and schools were selected on the basis that they were closest to the area in which households were selected. Interviews and self-administered questionnaires in each location inquired into lifetime and last-year prevalence of sexual abuse, and its correlates among children aged 15-17 years, whose parents gave informed consent and they themselves gave informed assent.

FINDINGS

The final household sample was 5631 (94·6% participation rate). 9·99% (95% CI 8·65-11·47) of boys and 14·61% (95% CI 12·83-16·56) of girls reported some lifetime sexual victimisation. Physical abuse, emotional abuse, neglect, family violence, and other victimisations were all strongly associated with sexual victimisation. The following were associated with greater risk of sexual abuse (adjusted odds ratio [OR]); school enrolment (OR 2·12, 95% CI 1·29-3·48); rural dwelling (0·59; 0·43-0·80); having a flush toilet (1·43, 1·04-1·96); parental substance misuse (2·37, 1·67-3·36); being disabled (1·42, 1·10-1·82); female (but not male) caregivers' poor knowledge of the child's whereabouts, friends, and activities (1·07, 0·75-1·53) and poor quality of the relationship with the child (ie, poor acceptance; 1·20, 0·55-2·60). The child's own substance misuse (4·72, 3·73-5·98) and high-risk sexual behaviour (3·71, 2·99-4·61) were the behaviours most frequently associated with sexual abuse, with mental health conditions found to be less prevalent than these factors but still strongly associated with sexual victimisation (post-traumatic stress disorder 2·81, 1·65-4·78; depression 3·43, 2·26-5·19; anxiety 2·48, 1·61-3·81).

INTERPRETATION

Sexual violence is widespread among both girls and boys, and is associated with serious health problems. Associated factors require multisectoral responses to prevent sexual violence or mitigate consequences.

FUNDING

UBS Optimus Foundation.

Finding solid ground: law enforcement, key populations and their health and rights in South Africa

INTRODUCTION

Sex workers, people who use drugs, men who have sex with men, women who have sex with women and transgender people in South Africa frequently experience high levels of stigma, abuse and discrimination. Evidence suggests that such abuse is sometimes committed by police officers, meaning that those charged with protection are perpetrators. This reinforces cycles of violence, increases the risk of HIV infection, undermines HIV prevention and treatment interventions and violates the constitutional prescriptions that the police are mandated to protect. This paper explores how relationship building can create positive outcomes while taking into account the challenges associated with reforming police strategies in relation to key populations, and vice versa.

DISCUSSION

We argue that relationships between law enforcement agencies and key populations need to be re-examined and reconstituted to enable appropriate responses and services. The antagonistic positioning, "othering" and blame assignment frequently seen in interactions between law enforcement officials and key populations can negatively influence both, albeit for different reasons. In addressing these concerns, we argue that mediation based on consensual dialogue is required, and can be harnessed through a process that highlights points of familiarity that are often shared, but not understood, by both parties. Rather than laying blame, we argue that substantive changes need to be owned and executed by all role-players, informed by a common language that is cognisant of differing perspectives.

CONCLUSIONS

Relational approaches can be used to identify programmes that align goals that are part of law enforcement, human rights and public health despite not always being seen as such. Law enforcement champions and representatives of key populations need to be identified and supported to promote interventions that are mutually reinforcing, and address perceived differences by highlighting commonality. Creating opportunities to share experiences in mediation can be beneficial to all role-players. While training is important, it is not a primary mechanism to change behaviour and attitudes.

Violence, violence prevention, and safety: a research agenda for South Africa

Violence is a serious problem in South Africa with many effects on health services; it presents complex research problems and requires interdisciplinary collaboration. Two key meta-questions emerge: (i) violence must be understood better to develop effective interventions; and (ii) intervention research (evaluating interventions, assessing efficacy and effectiveness, how best to scale up interventions in resource-poor settings) is necessary. A research agenda to address violence is proposed.

Psychosocial factors associated with self-reported male condom use among women attending public health clinics

BACKGROUND

Previous research has identified factors associated with condom use. However, less information exists on the impact that a history of sexually transmitted disease (STD) has on condom use.

GOAL

To identify factors associated with self-reported male condom use that relate to a history of STD.

STUDY DESIGN

Women attending STD clinics completed a survey that assessed sexual behavior, STD history, and psychosocial characteristics. Binomial regression was used to estimate the association between these factors and condom use.

RESULTS

Of the 12 factors included in the regression model, 11 were significant for all women. When the analysis was stratified by STD history, high condom use self-efficacy, high convenience of condom use, and high frequency of condom use requests were significantly associated with increased condom use among women with or without a history of STD. Factors such as greater perceived condom use norms, higher perceived level of risk, and greater need for condom use in long-term relationships were significantly associated with increased condom use among women with a history of STD. Factors such as shorter duration of a relationship, less violence in the relationship, and lifetime drug use were associated with increased condom use among women with no history of STD.

CONCLUSIONS

The pattern of psychosocial factors determining condom use is modified by a positive history of STD. These findings suggest that a history of STD could be an important factor in targeting condom use interventions.

Female condom use among women at high risk of sexually transmitted disease

CONTEXT

Whereas the female condom has been evaluated in many hypothetical acceptability or short-term use studies, there is little information about its suitability for the prevention of sexually transmitted diseases (STDs) or HIV over extended periods of time.

METHODOLOGY

As part of a six-month prospective follow-up study of 1,159 STD clinic patients, clients were interviewed during their initial visit, exposed to a behavioral intervention promoting condoms, given a physical examination and provided with instructions on completing a sexual diary. Potential predictors of trying the female condom were evaluated using logistic regression, and three condom-use groups (exclusive users of female condoms, exclusive users of male condoms and users of both types of condoms) were compared using multinomial regression.

RESULTS

Among 895 women who reported having engaged in vaginal intercourse during the study period, one-half had sex with only one partner, while one-quarter each had two partners or three or more partners. A total of 731 women reported using the female condom at least once during the follow-up period--85% during the first month of follow-up. Multiple logistic regression analyses indicated that employed women and those with a regular sexual partner at baseline were significantly more likely to try the female condom. By the end of the follow-up period, 8% of participants had used the female condom exclusively, 15% had used the male condom exclusively, 73% had used both types of condom and 3% had used no condoms. Twenty percent of women who tried the female condom used it only once and 13% used it twice, while 20% used 5-9 female condoms and 32% used 10 or more. Consistent condom users (N=309) were predominantly users of both types of condom (75%), and were less often exclusive users of the male condom (18%) or the female condom (7%). According to a multivariate analysis, women who used the female condom exclusively or who mixed condom types were more likely to be black, were more likely to be employed and were more likely to have a regular partner than were users of the male condom.

CONCLUSIONS

Women at risk of STDs find the female condom acceptable and will try it, and some use it consistently. Mixing use of female condoms and male condoms may facilitate consistent condom use. The female condom may improve an individual's options for risk reduction and help reduce the spread of STDs.

Effectiveness of an intervention promoting the female condom to patients at sexually transmitted disease clinics

OBJECTIVES

This study evaluated a behavioral intervention designed to promote female condoms and reduce unprotected sex among women at high risk for acquiring sexually transmitted diseases (STDs).

METHODS

The effect of the intervention on barrier use was evaluated with a pretest-posttest design with 1159 female STD clinic patients.

RESULTS

Among participants with follow-up data, 79% used the female condom at least once and often multiple times. More than one third of those who completed the study used female condoms throughout follow-up. Use of barrier protection increased significantly after the intervention, and high use was maintained during a 6-month follow-up. To account for attrition, the use of protection by all subjects was projected under 3 conservative assumptions. The initial visit and termination visit projections suggest that use increased sharply after the intervention and declined during follow-up but remained elevated compared with the baseline.

CONCLUSIONS

Many clients of public STD clinics will try, and some will continue, to use female condoms when they are promoted positively and when women are trained to use them correctly and to promote them to their partners. A behavioral intervention that promotes both female and male condoms can increase barrier use.

Mechanical failure of the latex condom in a cohort of women at high STD risk

BACKGROUND AND OBJECTIVES

Mechanical failure may reduce the efficacy of condoms. Little is known about frequency and determinants of condom failure in groups at high risk of sexually transmitted diseases (STD).

GOAL

To measure condom breakage and slippage rates and evaluate potential determinants of failure among women attending a public STD clinic.

STUDY DESIGN

Women attending an STD clinic participated in a 6-month prospective study of barrier contraception for the prevention of STD. They completed sexual diaries that were reviewed at monthly follow-up visits. No data were collected from the male partners. Baseline characteristics of the participants and time-dependent behaviors were evaluated as potential determinants of condom failure.

RESULTS

Of 21,852 condoms used by 892 women, 500 broke during intercourse (2.3%) and 290 slipped (1.3%). Breakage was more common among young, black, single nulliparae who engaged in high-risk behavior. Slippage was more common among married women with children. Failure rates decreased with condom use, with coital frequency, and with use of spermicides.

CONCLUSION

User characteristics and experience are determinants of breakage and slippage, which are often regarded only as the effect of product design flaws. Attention to modifiable determinants of failure may improve user counseling and product labeling.

Prospective study of barrier contraception for the prevention of sexually transmitted diseases: study design and general characteristics of the study group

BACKGROUND AND OBJECTIVES

The AIDS epidemic has brought barrier contraceptives to the forefront of public health research. A comprehensive evaluation of the efficacy of barrier contraceptive use in preventing sexually transmitted diseases (STDs), including AIDS, is necessary to inform both potential users and public health policy makers. This study was undertaken to evaluate the efficacy of condoms and vaginal spermicide products, used alone or in combination, in preventing gonorrhea and chlamydia among women attending an STD clinic.

GOAL OF THIS STUDY

To describe the general characteristics of the study group and its follow-up experience.

STUDY DESIGN

Women who met the eligibility criteria were invited to participate. The initial visit included an interview, a behavioral intervention promoting barrier methods, a physical examination, and instructions to complete a sexual diary. Participants received free barrier contraceptives and returned for six monthly follow-up visits. DESIGN RESULTS: Participants (n = 1,122) were low income, single (74%) black (89%) women with a median age of 24. The behavioral intervention led to the use of barrier protection in more than 70% of reported acts of vaginal intercourse. Barriers were used consistently (100% of sexual acts) during 51% of the months of follow-up. A total of 148 cases of gonorrhea (28 per 1,000 months) and 122 cases of chlamydia infection (23 cases per 1,000 months) were diagnosed during follow-up.

CONCLUSION

This study represents a practical solution to a complex set of design considerations. The study protocol was successful in promoting consistent and proper use of barrier methods.

Health education for pregnant smokers: its behavioral impact and cost benefit

OBJECTIVES

A randomized trial (the Birmingham Trial II) was conducted to evaluate the behavioral impact of health education methods among 814 female smokers at four public health maternity clinics.

METHODS

Four hundred patients were randomly assigned to an Experimental (E) Group, and 414 were assigned to a Control (C) Group. Self-reports and saliva cotinine tests confirmed smoking status at the first visit, at midpregnancy, and at end of pregnancy.

RESULTS

The E Group exhibited a 14.3% quit rate and the C Group an 8.5% quit rate. A Historical Comparison (C) Group exhibited a 3.0% quit rate. Black E and C Group patients had higher quit rates than White E and C Group patients. A cost-benefit analysis found cost-to-benefit ratios of $1:$6.72 (low estimate) and $1:$17.18 (high estimate) and an estimated savings of $247,296 (low estimate) and $699,240 (high estimate).

CONCLUSION

Health education methods are efficacious and cost beneficial for pregnant smokers in public health maternity clinics.

Community change agents and health interventions: hypertension screening

This study explores a community-based approach to health care. Community volunteers were trained and then conducted door-to-door screening for hypertension. Three large apartment complexes were selected for screening. In the two experimental communities, a letter was sent to each household soliciting volunteers who were then trained to measure blood pressure, complete data sheets, gain admittance to houses, and make appropriate recommendations for medical consultation. The residents in the control community received letters informing them of the hours during which they could have their blood pressure checked free of charge in the apartment complex rental office. Chi-square tests on number of apartments screened indicated the experimental door-to-door screening methods was significantly more effective than the control central site method. These results demonstrate that the experimental screening project was a highly effective and inexpensive technique for hypertension screening.