Profile
Medicine and Activism: Institutionalising Medical Care and Compassion for Rape Survivors
Simidele Dosekun
The Heath Sciences Faculty of the University of Cape Town has the oldest medical school in Southern Africa, initiated in 1912 as a Faculty of Medicine. It currently operates in alliance with the Groote Schuur Teaching Hospital and the Red Cross Children’s Hospital. As a large faculty, with five separate schools and eleven multifaceted departments, it is responsible for the teaching and training of hundreds of young doctors, research specialists, surgeons and nurses annually.
Medical schools are globally renowned for their patriarchal cultures; they are often steeped in very traditional notions of gender roles, and associated with positivist approaches to research which are not always sensitive to the complexities of men’s and women’s social realities. But even within the most formidable patriarchal institutions and traditions, it is often possible to find expert activists working – sometimes without recognition or fanfare, but with great courage and skill – to address gender injustices.
Professor Lynette Denny and Dr Nomonde Mbatani are two such experts, located in the UCT Department of Obstetrics and Gynaecology, and at Groote Schuur Hospital. They work as specialists in the field of gynaecology oncology and as a team, offer their patients a particularly rare combination of medical and surgical skills. Because of their surgical expertise, Denny and Mbatani perform reconstructive surgery upon women survivors of the most violent rapes in the Western Cape Province of South Africa. This critical care takes place in the context of a widely acknowledged rape crisis in the country. Together with Denny’s policy work, it has motivated institutional and cultural changes at Groote Schuur Hospital to improve the treatment of all rape survivors. This profile focuses on this particular aspect of the doctors’ work (although it is only one facet of their overall medical engagement with women’s healthcare) and offers a brief overview of gender activism by two women which challenges the intersections of professional medical care and the meaning of political compassion and advocacy within everyday gendered realities.
Denny specialised in gynaecology oncology in 1993, while Mbatani, her former student, joined her in 2003. Denny’s work in the field has gained her widespread recognition in South Africa and abroad, including a 2003 award as South Africa’s Woman of the Year in Science and Technology, for her work on cervical cancer in poverty-stricken urban environments of South Africa. Surgery as a whole still tends to be dominated by men because of the demanding working hours, but both Denny and Mbatani (senior surgeons in their unit) note that the gender profile is gradually shifting. The obstetrics and gynaecology (“obs and gynae”) unit in which they work is, for instance, almost evenly split between men and women surgeons.[1] At the same time, they explain that “obs and gynae” is becoming a less desirable specialisation, because it carries for the doctor a high risk of exposure to HIV.
Having women gynaecologists is very important, Mbatani considers, because it encourages their patients to feel more at ease. This is true for all women seeking help, but in rape cases where the patients have just suffered violence, humiliation and indecent exposure at the hands of a man, the need for women surgeons is especially critical. When rape survivors come into the hospital (usually, but not always, after having reported their assaults2) they have to recount their experiences and expose their bodies to the doctor for medico-legal purposes, all of which they may find easier to do with a woman doctor. Furthermore, Mbatani explains that, “being black comes as a bonus to our female patients especially in the public sector and this is one reason I am still here.”
Most of the severe rape cases she and Denny see come from the largely underprivileged population served by Groote Schuur, a public hospital and they tend to be black and coloured women with relatively little education. In Mbatani’s experience, it is important for such women to relate to a doctor who understands their social background, “someone that they consider to be ‘one of us,’ someone who speaks in their own mother tongue.”
The majority of rapes of women in South Africa do not involve extensive physical damage (although the “minor” damages – bruises, spinal trauma, vaginal tears and scratches – and gross psychological damages are serious). But Denny and Mbatani annually encounter five to ten cases of women who have sustained very severe physical injuries inflicted by brute force and all manner of weapons during rape. As Denny notes, most of such cases become homicides because the women die from the extent of their injuries.
Denny’s work with “severe” rape victims, as indeed with all her patients, is informed by her feminist principles. Denny is a well-known activist around gender-based violence; she served as Chair of the Rape Crisis Cape Town Board for many years and won a White Ribbon award for her work with rape survivors. She has developed critical protocols for handling the medical and legal care of survivors, and has worked within UCT for many years on the development and implementation of institutional sexual harassment policies.
When a woman arrives at the hospital, after surviving sexual attacks with bottles, knives, or other implements used by perhaps multiple assailants, the trauma done to her body is substantial and even horrifying. Denny explains, though, that she has learnt over the years that treating a rape patient while enraged about the patient’s victimisation prevents the carer from fully caring for the patient: “it leaves one feeling helpless and angry in the face of the suffering.”
What is the alternative to rage, in such circumstances? “The best way I know to approach and help rape survivors is to fully focus my energy, attention and compassion upon them, as a professional doctor,” says Denny.
Mbatani concurs with this approach, as she views her role in these cases, and her teaming with Denny, as that of doctor and healer, not feminist or activist. Working with rape survivors, she says, “requires a lot of understanding and patience from the practitioner”. On the one hand, the doctor must show the patient empathy and respect, and give her space in which to express her emotions. At the same time, it is her role to medically assess the patient, accurately record her story, for which purpose one may have to repeat questions, and collect the necessary forensic evidence. This kind of evidence collection is essential to ensuring a successful prosecution, if a charge has been laid. The doctor therefore has to guide the patient through a detailed restaging of her rape experience which is often traumatic and difficult not just for the survivor, but the doctor too.
Through Denny’s activism, critical steps have been taken to create support structures for this difficult interaction between doctor and patient. First, in 1994, Denny pushed to establish a rape centre at Groote Schuur. This is a private space in which non-critical rape survivors coming into the hospital are seen immediately by a nurse and the attending gynaecologist, and where they can shower and change into new clothes after being treated. Although Denny had to raise private funds to establish the centre, called the Thuthuzela Room, she considers that the hospital is actually “supportive and wishes to provide the best possible service to rape survivors”. Groote Schuur Hospital has contributed money and facilities such as a shower to the rape centre. The hospital also provides post-exposure prophylaxis (PEP) to the rape survivors who come into the room to minimise their risk of contracting HIV.
Subsequently, in 1998, the Western Cape Province adopted a set of protocols designed by Denny to integrate the clinical and forensic care of rape survivors. The protocols consist of a comprehensive form which the attending doctor must go through with the survivor and meticulously complete – a lengthy process taking roughly three hours. Denny checks through the documentation of every rape case, severe and non-severe, that is seen at Groote Schuur Hospital to ensure that the process is being correctly followed. To this same end, registrars are re-trained on the protocols every six months.
Denny celebrates the adoption of the protocols as “a move from policy to practice”. Together with the training accompanying them, they serve to demystify rape for young (and older) doctors. They normalise the care of survivors as “something that a doctor does”. Indeed, Denny reports that junior doctors who previously felt intimidated by the prospect of working with rape survivors now say that they feel able to do so with greater ease and professionalism. She has taught them that their responsibility to these survivors is not to presume to pyschologically heal them. Rather it is to create a safe and contained space for these women, and to examine and interact with them with respect.
Changes to the teaching curriculum have also helped institutionalise care for rape survivors at Groote Schuur. Denny’s curriculum for students includes input from NGO’s (such as Rape Crisis) on the issues facing survivors of sexual assault, so that student-doctors can begin to situate their own responsibilities as medical practitioners within a wider spectrum of services and support. Denny and Mbatani say that questions on handling rape cases now regularly appear specialist gynaecology exams.
The care of male rape survivors at Groote Schuur has been a more contentious issue. This speaks to the gendered culture of the institution against which Denny and Mbatani work. Mbatani explains that male surgeons at the hospital initially refused to examine male rape survivors, agreeing to be called only if it had been determined by another doctor that these patients required surgery. These surgeons argued that male survivors, like their female counterparts, should be seen by a gynaecologist. This was of course an illogical argument given that gynaecology is the specialisation on the female reproductive system, and that the physical damage experienced by male survivors did not require the expertise of gynaecologists. Ultimately, the reluctance of the surgeons to see male survivors stemmed from the view that such men were likely to be homosexuals, and it seems likely that homophobia (and a lack of understanding about rape as a form of assault) lay at the root of the male surgeons’ attitude.
Male rape is still widely misunderstood within South Africa; to the outrage of many feminist activists, it has not been legally defined as “rape” within the new Sexual Offences Act. Male rape is, in the public mind, mostly associated with the gang-cultures operating within prisons, and so ignored as an issue of crime amongst criminals.
According to Denny and Mbatani, the male surgeons’ prejudice placed both male rape survivors and gynaecologists at Groote Schuur in an untenable position. On the one hand, male survivors tend to recoil from examination by a woman doctor because of the sensitivity of their experiences. Conversely, before the establishment of the rape centre, the gynaecologists did not know where to examine these patients. Mbatani recalls once seeing a male rape survivor and explains that she did not know where to ask him to wait. Had he waited for examination in the gynaecology room, he would have stood out as the only man there and would therefore have been subject to great curiosity, such that his privacy might have been compromised. In this particular case, the patient ended up pacing the corridors of the hospital, before eventually seeing a doctor hours after he had come in for treatment and care.
The standoff with the male surgeons over the care of male rape survivors was eventually resolved when the hospital administration intervened and made it mandatory for them to see such patients. As suggested, their initial reluctance to do so could be read as indicative of the gendered institutional culture that prevailed within the hospital institution, if not officially sanctioned by it. Arguably, the surgeons’ attitude towards male rape survivors, as described by Denny and Mbatani, was premised on two fundamental notions about rape. The first is that rape feminises; the second is that there is stigma and shame in being raped – which, for a man is also, therefore, to be feminised. These ideas translated into the care of rape survivors in that this caring itself was perceived to be feminising. Within the culture and hierarchies of doctors at a hospital such as Groote Schuur, the care of male rape victims was regarded as being something that male surgeons, at the top of the pecking order, should not be bothered with.
In the end, it is interesting that despite entrenched ideas about rape as “something which happens to women, and which women must address”, the hospital as an institution took an official position on this matter. That they did so arguably relates directly to Denny and Mbatani’s medical work and efforts on behalf of rape survivors. Denny states that their work for rape survivors “has made the hospital very sensitive; its made sure that we provide a very high-level service”. Certainly, the adoption of protocols and policies do not guarantee that every survivor will have a positive experience in their interaction with the hospital institution and staff. Yet Denny’s explicit activism, consolidated by Mbatani’s medical and surgical work for rape survivors, is implanting the roots of a new culture at the hospital in attitudes towards rape survivors. It is increasingly expected as a matter of due professional course that rape survivors, female and male, must receive due and diligent medical care; compassion too.
The ramifications of this for the Faculty of Health Sciences at UCT are powerful. Feminist medical science and practice are being embedded and normalised as part of the day-to-day routine of teaching and healing.
Denny and Mbatani are not starry-eyed about their work, acknowledging that there are continuing institutional, professional and personal challenges in taking on the politics of gender injustice. But, their collaboration has already demonstrated the power of alliances of science and activism in the critical work of re-imagining the spaces of professional medicine as spaces in which women’s lives and dignity are cherished.
Professor Denny and Dr Mbatani were interviewed at UCT’s Health Sciences Faculty.
Endnotes
1 Eight of fifteen surgeons in the “obs and gynae” unit are women.
2 South African research on the ratio between reported and un-reported rapes is complex, and an area in which there are numerous debates about how to quantify gender-based violence. A study of the prevalence of rape by the South African government statistics body, Stats SA, in 2001, suggests that half of those who experience rape report it. Another study based on interviews with women in a health care facility for rape (Medical Research Council, 1999) suggests that 29% of the women had reported. Rape Crisis Centres report much lower figures for reporting, and point out that what gets called “rape” covers a very diverse range of sexual assaults.
Simidele Dosekun
served on the FA team as editorial assistant and reviews editor from 2006-2007, and recently completed a Master’s Degree in Gender Studies at the African Gender Institute.