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.

The no-go zone: a qualitative study of access to sexual and reproductive health services for sexual and gender minority adolescents in Southern Africa.

BACKGROUND: Adolescents have significant sexual and reproductive health needs. However, complex legal frameworks, and social attitudes about adolescent sexuality, including the values of healthcare providers, govern adolescent access to sexual and reproductive health services. These laws and social attitudes are often antipathetic to sexual and gender minorities. Existing literature assumes that adolescents identify as heterosexual, and exclusively engage in (heteronormative) sexual activity with partners of the opposite sex/gender, so little is known about if and how the needs of sexual and gender minority adolescents are met. METHODS: In this article, we have analysed data from fifty in-depth qualitative interviews with representatives of organisations working with adolescents, sexual and gender minorities, and/or sexual and reproductive health and rights in Malawi, Mozambique, Namibia, Zambia and Zimbabwe. RESULTS: Sexual and gender minority adolescents in these countries experience double-marginalisation in pursuit of sexual and reproductive health services: as adolescents, they experience barriers to accessing LGBT organisations, who fear being painted as "homosexuality recruiters," whilst they are simultaneously excluded from heteronormative adolescent sexual and reproductive health services. Such barriers to services are equally attributable to the real and perceived criminalisation of consensual sexual behaviours between partners of the same sex/gender, regardless of their age. DISCUSSION/ CONCLUSION: The combination of laws which criminalise consensual same sex/gender activity and the social stigma towards sexual and gender minorities work to negate legal sexual and reproductive health services that may be provided. This is further compounded by age-related stigma regarding sexual activity amongst adolescents, effectively leaving sexual and gender minority adolescents without access to necessary information about their sexuality and sexual and reproductive health, and sexual and reproductive health services.

"The care is the best you can give at the time": Health care professionals' experiences in providing gender affirming care in South Africa.

BACKGROUND: While the provision of gender affirming care for transgender people in South Africa is considered legal, ethical, and medically sound, and is-theoretically-available in both the South African private and public health sectors, access remains severely limited and unequal within the country. As there are no national policies or guidelines, little is known about how individual health care professionals providing gender affirming care make clinical decisions about eligibility and treatment options. METHOD: Based on an initial policy review and service mapping, this study employed semi-structured interviews with a snowball sample of twelve health care providers, representing most providers currently providing gender affirming care in South Africa. Data were analysed thematically using NVivo, and are reported following COREQ guidelines. RESULTS: Our findings suggest that, whilst a small minority of health care providers offer gender affirming care, this is almost exclusively on their own initiative and is usually unsupported by wider structures and institutions. The ad hoc, discretionary nature of services means that access to care is dependent on whether a transgender person is fortunate enough to access a sympathetic and knowledgeable health care provider. CONCLUSION: Accordingly, national, state-sanctioned guidelines for gender affirming care are necessary to increase access, homogenise quality of care, and contribute to equitable provision of gender affirming care in the public and private health systems.

"They treat us like we're not there": Queer bodies and the social production of healthcare spaces.

There is significant literature demonstrating the interpenetrability of identity and space, yet there is almost no work that explores the co-production of queer identities and healthcare spaces. We use Lefebvre's triad of (social) space to explore how the social spaces of South African healthcare facilities shape and are shaped by queer service-users, drawing on data from interviews and focus group discussions with 29 queer service-users and 14 representatives of organisations. Findings reveal that healthcare spaces are produced by the spatial ordering of health policy inattentive to queer health needs; the enduring symbolic representations of queerness as pathological or 'un-African'; and various identity assertions and practices of individuals, including queer service-users and healthcare providers. As a result, healthcare spaces are overwhelmingly heteronormative, although queer service-users' subversive practices suggest alternative spatial configurations. However, such resistance relies on individual empowered action and risks disciplining responses. Wider efforts are needed to transform the material and ideological space of healthcare facilities through law and policy reform and continuing professional training for healthcare providers.