Gender-based violence (GBV), which includes actual or threatened physical, sexual or psychological harm, coercion or derivation of liberty, is a significant global health and societal issue (World Health Organization [WHO] 2017). It has been estimated that one in three women across the world will experience GBV in their lifetime (WHO 2017). Furthermore, as a result of the pandemic, the United Nations (UN) referred to the rise of domestic violence as a ‘shadow pandemic within the pandemic’ urging countries to address this with urgency (UN 2020) or a ‘twin pandemic’ (Dlamini 2021).

Although included within the wider definition of GBV, sexual violence as a separate entity has been defined as the following:

Clinical forensic centres, which are located next to the hospitals, treat victims who have been exposed to sexual violence. The centres provide positive treatment for victims as well as clinical forensic medical services. The nurses assess, screen and interview the victims and then proceed to conduct the examination. The forensic medical services provided include a medical examination and the collection of quality specimens for laboratory analysis, which leads to an increase in successful prosecutions of perpetrators and provides communities with confidence (Randa & Mokoena 2019).

The impact of sexual violence on the psychological well-being of those who experience harm can be wide-ranging, including behavioural changes, sleep and eating disorders, post-traumatic stress disorder (PTSD), depression and increased risk of attempting or committing suicide (Jina & Thomas 2013; Naidoo 2013; Sepeng & Makhado 2018). In addition, the physical impact may also extend to significant harms such as unwanted pregnancy and sexually transmitted diseases, including hepatitis B and HIV (Jina & Thomas 2013).

Although sexual violence is a global issue, it has been identified as a large-scale problem in South Africa (Moffett 2006). Kaswa (2021) noted that the coronavirus disease 2019 (COVID-19) pandemic saw a major reduction in accessible healthcare facilities by survivors, including TCCs, during the lockdowns. In 2013–2014, 62 649 sexual offence cases (of which 46 253 cases were rape) were reported to the South African Police Service (Abrahams & Gevers 2017). It has also been estimated that up to half of all women in South Africa experience a lifetime history of physical or sexual violence from a partner (Watt et al. 2017).

A localised study in one South African Province (North-West, Rustenburg) reported that one in four women aged between 18 and 49 years had experienced rape in their lifetime. One in five of these women contracted HIV (Lamola 2017). It is more recently reported that during the pandemic in South Africa, one woman was killed every 3 h (Kaswa 2021). Despite all these stated figures, it has also been observed that this is likely to be an underrepresentation of the real numbers of sexual violence against woman and may only be the ‘tip of the iceberg’, as many cases are not formally reported and/or do not enter the criminal justice system (Sebaeng, Davhana-Maselesele & Manyedi 2016; Steinbrenner et al. 2017). Indeed, a nationwide study in South Africa found that only one in nine women reported being raped to the police (Jewkes & Abraham 2002), and many instances of rape or sexual violence are not reported for fear of retrauma and a lack of confidence in the legal system (Jewkes & Abraham 2002; Rohrs 2011), as emphasised in the records review conducted by Kaswa (2021) that reports a dramatic reduction in attendance and reporting by women at one major TCC.

An enormous amount of work has been undertaken to highlight the experiences of survivors of sexual violence, predominately rape (Abrahams & Gevers 2017; Steinbrenner et al. 2017); there is limited research focusing on the healthcare experiences from the viewpoint of women themselves when they first encounter healthcare provision whether that be 1 of the 54 TCCs located across South Africa (Kaswa 2021). Healthcare facilities and healthcare professionals are often the first port of call for many survivors of sexual violence (McGarry & Hinsliff-Smith 2020). They are often custodians for the care and welfare of survivors, as they help to navigate the next steps to support and referral as well as providing necessary medical care.

Sexual violence can have long-term, debilitating effects on the mental health of victims. Delara (2016) shared that one common form of mood disorders that has been observed in female victims is depression. According to Meekers, Pallin and Hutchinson (2013), feelings of fear, depression, dysthymia and panic were reported as mental consequences by women who experienced violence. The sentiments are echoed by Oshodi et al. (2020), who in their study indicated that symptoms of anxiety, depression and PTSD were found to be persistent among adolescents (study participants aged 14–18), underlining the need for long-term support, screening and evidence-based follow-up care.

The provision of support from healthcare facilities can help to alleviate some of the long-term effects of sexual violence (Abrahams & Gevers 2017), with a need for competent and compassionate healthcare professionals (Rohrs 2011). The WHO found that most healthcare workers in primary healthcare settings do not receive adequate mental healthcare training (Kigozi & Ssebunnya 2009). Again, nurses’ lack of knowledge in managing patients with mental health disorders has resulted in the underdiagnosis of most mental health conditions in primary healthcare (Siddiqi & Siddiqi 2007). The study further found that primary healthcare nurses managing patients at the clinic were not adequately qualified to provide all of the services that are provided in clinics that use a one-stop shop approach (Hlongwa & Sibiya 2019).

To explore these issues further, this review focused on the first point of contact and women’s interactions with healthcare services who have been sexually assaulted, in order to identify how care can be improved for survivors of sexual violence in South Africa at this crucial time. Although literature relating to the assessment of South African follow-up services (Abrahams & Gevers 2017; Lamola 2017) and the procedures and protocols for HIV follow-ups is available (Watt et al. 2017), this routine provision is not the focus for this review because failing to meet the needs of women at the initial stage of seeking healthcare assistance is often paramount to their overall recovery. We also acknowledge that there is ongoing work to understand and resolve the poor HIV adherence and attendance at follow-up appointments by authors in the field (e.g., Holton, Joyner & Mash 2018; Rohrs 2011).

In their study, Sepeng and Makhado (2018) indicated that PTSDs and depression are common among survivors seeking healthcare in TCCs post-rape experiences in South Africa. However, one study reported that adult rape survivors who reported rape in TCCs were not given follow-up care to screen and manage PTSD post-rape experiences (Sepeng & Makhado 2019). It is worth noting that mental healthcare management for rape survivors diagnosed with PTSD and depression requires about 12 sessions with the therapist when using treatment modalities such as cognitive behavioural therapy (CBT), exposure therapy (ET), cognitive processing therapy (CPT), et cetera and this type of care is mostly given in specialised care services such as hospitals. Hence, it is impossible to manage rape survivors diagnosed with these disorders in TCCs.

The methodology for this review complies with the PRISMA guidelines for systematic reviews (Liberati et al. 2009). The review was conducted in accordance with the protocol, which is registered with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42019121580).

The five studies included in this review provide a broad but limited and very sparse view of the experiences of women survivors of sexual violence in South Africa. This review synthesises the limited work that has been conducted within the context of healthcare settings, identifies shortcomings in service provision from the perspectives of survivors and includes empirical studies, which were conducted prior to the global pandemic. We would draw readers to consider work that has been conducted on access to healthcare services by survivors of sexual violence, including work in South Africa during the pandemic, for example, work by Kaswa (2021), which reports the dramatic decrease in reported patient cases in one region of South Africa.

Although only five studies were located, the quality of the reporting, including ethical procedures, provides a useful indicator for the current understanding of sexual violence survivors and their experiences of healthcare provision in South Africa. It is clear that there is much work to be conducted to fully understand the needs of adult female survivors of sexual violence in South Africa. A major problem in understanding women’s experiences is that only 1 in 25 women who experience sexual assault actually report it to the police authorities (Holton et al. 2018) in South Africa and as a consequence are therefore highly unlikely to seek medical attention. What is reported in these five studies illustrates that this indeed could only be the ‘tip of the iceberg’.

A holistic and integrated approach is required for women who have experienced sexual violence in South Africa. This needs to start with the police and linking with healthcare professionals within clinical and therapeutic settings and indeed was highlighted in the Lamola report (2017). This is not only a pressing need, not least highlighted with the widespread pandemic in South Africa but also necessary for the mental health and well-being of sexual violence survivors.

A comprehensive report conducted by Rohrs (2011) working with non-governmental organisations (NGOs) found a clear distinction between referral support information that can be provided by police officers to survivors and the role of healthcare facilities and specialist TCC settings. The administering of PEP for the prevention of HIV infection is part of the National Instructions (Section 9, 12) and is a public right for those who have been sexually assaulted (Lamola 2017; Nare 2013). However, it is recognised that there is a currently low uptake and adherence (Lamola 2017; Nare 2013). It is therefore imperative that those engaging with survivors, including healthcare professionals, provide the appropriate advice and guidance about PEP adherence, including the administering of anti-nausea medication. A lack of information from healthcare professionals at the time of administering necessary drugs may be a reason for the low adherence rates in South Africa and the continued high prevalence of HIV and STIs (Rohrs 2011; Schneider et al. 2016).

It is clear that there is a distinct legal process in place for survivors to report incidents and to seek medical attention at either specialist TCC or at acute settings. However, there is still considerable stigma attached to rape and sexual assault, which is underreported and has the added complication of a possible positive HIV outcome. Evidence is clear that many women, who are HIV-positive, are also rape survivors (Meel 2003). This presents a challenge for public health authorities in South Africa for providing support that meets the needs of survivors of both sexual violence and HIV while also ensuring that follow on support is integrated and meaningful to the growing number of survivors who are now encouraged to report assault. South Africa finds itself with a triplicate of dilemmas. It is a country dominated by a history of HIV, a neglected healthcare system with a mixture of public and private provision, and a systemic acceptance of daily accounts of rapes.

This review is the first to synthesise any empirical research that explores women’s experiences of healthcare services following sexual violence in South Africa. Shortcoming of existing services have been highlighted. Given the prevalence of sexual violence in the country, this work is imperative for emphasising the need to improve services for the large number of women who experience sexual abuse and violence in South Africa. This includes reviewing the impact of the pandemic on service provision for survivors (Kaswa 2021). The number of included studies (n = 5) is limited because of a lack of published research in this area, and those that have been included have shown a robust research procedure and given a voice to their female participants which may not have otherwise been heard.

This review has not included studies that have focused predominately on HIV adherence by survivors of sexual violence or indeed ongoing interventions in relation to HIV offered by TCC, healthcare facilities or NGOs. Likewise, studies focusing on the legal system or police involvement in sexual violence disclosures have not been included. This review aimed to identify evidence whereby survivors of sexual violence have shared their experiences about contact with healthcare facilities as a means to describe women’s experiences in South Africa, which is often neglected and currently lacking in the literature. Future work could benefit from a broader inclusion of women’s experiences with police, the legal systems and follow-up services and how these may impact pursuit of medical and psychological support by women.

In addition to the physical care that the victims are given, there is a need to provide the concomitant caring and emotional support needed during this period of confusion and to address the assault to human dignity on the patient who is a victim of sexual violence. Healthcare professionals have an expressed duty to treat the patient with respect, to be non-judgemental and to foster a caring nurse–patient relationship (Randa & Mokoena 2019). Healthcare practitioners should also offer the victims of sexual violence information on how and where they can access legal aid and counselling services. This calls for the need for an integrated multisectoral approach and holistic patient-centred care, emphasising the importance of attending follow-up for the survivors of sexual violence.

South Africa has conducted and published a few studies to date that have explored the survivor experiences of sexual violence. As such, this review encapsulates the multifaceted phenomenon of sexual violence within the particular context of South Africa from the perspective of women themselves. Geographically, it is also timely to remember that this is by no means unique, as sexual violence remains a significant global problem. With the inception of specialist care provision, TCCs for women who have experienced sexual violence in South Africa, these services have developed over the last four decades. However, as the present review highlights, alongside immediate care facilities, there needs to be a greater emphasis on sustained care pathways, combining mental health and psychological support for women post trauma. This requires substantial investment and resources, both financial support and wider resources including physical infrastructure and training. However, alongside any frontline service or care delivery development, the wider context of policy reform and systemic societal change with regard to prevailing assumptions and attitudes towards GBV need to be considered and are pivotal to this evolving health agenda. Further empirical work is required to fully understand and meet the needs of this often-hidden population. Given the stigma and societal complexities surrounding sexual violence, this needs to be understood through the lens of those who have experienced sexual harm. Post the COVID-19 pandemic, there is a duty to address this so-called ‘shadow pandemic’ not just in South Africa but globally (UN 2020).