Trauma Responsive Care

#### **Chapter 5**

## A Case Study on Transdisciplinary Approach to Eradicating Sexual Violence: Thuthuzela Care Centres

*Judy Dlamini*

#### **Abstract**

In 2010, South Africa had the highest rate of rape in the world at 132.4 incidents per 100,000 people; this decreased to 72.1 in 2019–2020. This could be an actual decline, or it could be due to other factors such as a sign of decrease in reporting and lack of trust in the criminal justice system. Executing its mandate to develop best practices and policies in the reduction of gender-based violence, the Sexual Offences and Community Unit (under the National Prosecuting Authority) introduced Thuthuzela Care Centres (TCCs) in 2006, one-stop facilities whose aim is to turn gender-based violence (GBV) victims to survivors through psychosocial, medical and legal support. A transdisciplinary approach is utilised in solving national challenges, including Departments of Justice, Health, Social Development, Treasury, and Non-Governmental Organisations who work with social workers to offer counselling. TCCs are the most cohesive intervention to date that seeks to prevent and eradicate GBVF. Accountability by each stakeholder from the opening of the case to its conclusion has improved conviction rates tenfold. The country requires more partnerships and transdisciplinary approaches to tackle national challenges, including SGBVF. It will take leadership and accountability by all parties to achieve success.

**Keywords:** gender-based violence and femicide, toxic masculinity, transdisciplinary approach, Thuthuzela Care Centres, social cohesion, accountable leadership

#### **1.

*Coercion can encompass varying degrees of force; psychological intimidation; blackmail or threats (of physical harm or of not obtaining a job/grade, etc.).*

There are numerous sources of data on the prevalence of sexual violence, including police reports, studies from clinical settings and non-governmental organisations and population-based surveys [2]. The latter is reported to have the best quality of data, with general underreporting of sexual violence. Reasons vary from lack of trust in the criminal justice system, shame, inadequate support systems, fear or risk of retaliation, fear or risk of being blamed, fear or risk of not being believed to fear or risk of being mistreated and/or socially ostracised [1]. The prevalence varies according to the type of violence and geography. In a cross-sectional survey amongst a randomly selected sample of men in South Africa, 14.3% of men reported having raped their current or former wife or girlfriend [3], while in a WHO multi-country study, lifetime prevalence of sexual partner violence reported by women, aged 15 to 49 years, ranged from 6% in Japan to 59% in Ethiopia, with rates in most settings falling between 10% and 50% [4].  In 80% of rape cases in the USA, the aggressor is known to the woman (victim) [6, 7]. Meanwhile in South Africa, the most recent survey of the prevalence of rape found that more than one in five men reported raping a woman who was not a partner (i.e. a stranger, acquaintance or family member), while one in seven reported raping a current or former partner [3]. Sexual violence is prevalent in all societies across geographies and social classes.

#### **2. Underlying factors to sexual violence**

Sexual and gender-based violence and femicide (SGBVF) is about gendered power inequality, which is rooted in patriarchy [8]. Culture and social beliefs play an important role in sexual violence; a culture of violence and male superiority tends to normalise violence against women and children, all forms of violence. This culture extends to safety and security officers who are supposed to protect women. When women report sexual violation and are subjected to secondary victimisation by police, where their account is not believed, this causes more emotional harm and delayed healing and discourages women from reporting crimes [9]. The culture of victim blaming, stereotyping and secondary victimisation of victims of SGBV by police is rife globally [10–12]. This is despite several studies that confirm the low rate of false reporting on sexual assault. A meta-analysis of seven studies found that the actual rate of false reporting (e.g. lying) about sexual assaults was low, approximately 5% [9].

In South Africa, different forms of violence date back to the violent apartheid system, which legislated for and institutionalised different forms of violence to control and repress the majority [13]. South Africa was listed in the 2018 Global Peace Index as one of the most violent and dangerous places on Earth which is not abating [13]. Galtung [14] described three types of violence, direct, structural and cultural. Direct or personal violence includes sexual violence and is enabled by easy access to weapons, a general climate of lawlessness and corruption within the criminal justice system [13]. Underlying

#### *A Case Study on Transdisciplinary Approach to Eradicating Sexual Violence: Thuthuzela Care… DOI: http://dx.doi.org/10.5772/intechopen.110836*

direct violence is structural violence, defined as personal and social violence, entrenched in unequal power relations embedded within society. The unequal power relations are gendered and racial and determine access to quality health and education [13]. Structural violence arises from unjust, repressive and oppressive political, economic and social structures that affect people's chances in life, while cultural violence is based on attitudes and beliefs that perpetuate discrimination, racism, prejudice and sexism. Systemic institutionalised patriarchy legitimises violence against women.

#### **3. Role of men**

Violence by men is associated with a patriarchal system and toxic masculinity. Toxic masculinity, a term coined by Shepherd Bliss (in [15]), is toxic behaviours by men as a reaction to perceived threats to the masculinity of a subset of men with poor self-esteem. Scholars posit that being a man is valued by most societies, while being a woman is devalued; therefore, when men who lack self-esteem do not receive external validation, it triggers toxic behaviour to 'regain' their masculinity. Many studies describe how young men have identified violence as an important way to display power and to prove their masculinity in their communities, including exerting control in intimate relationships with women. According to October [16], toxic masculinity is when the norms of masculinity that are defined as violent, unemotional and sexually aggressive have a harmful impact on society and the individual. However, toxic masculinity goes beyond that; male rape is severely underreported because vulnerability is constructed within gendered notions of femininity; negating the victim's masculinity, the violence affirms the masculinity of the perpetrator [16]. While most programmes designed to prevent GBV focus on women and how they should protect themselves, interventions to end gender-based violence need to involve men and boys to help them change their attitudes and behaviours, and even renegotiate their social position and identity [17]. Positive masculinity requires deliberate and consistent effort by all stakeholders to achieve social cohesion and a culture that celebrates equality across all social identities. In South Africa, a few intervention programmes have shown positive behaviour change amongst men and boys, such as One Man Can, Men as Partners and Steppingstones; however, a national roll-out is required to have sustainable change [18].

Most sexual violence is committed by male perpetrators; therefore, involving men and boys in prevention efforts requires holding them accountable for the ways that they contribute to sexual violence; they must be a major part of the solution of creating a culture free from gender-based violence [19]. It starts by raising responsible, sensitive young boys and girls who see all human beings as equals. Men and women need to unlearn the gendered socialisation, gendered roles and prejudice. More programmes are needed that are designed to teach boys and men acceptable behaviour towards women and people who are different from them. One such programme is Futures Without Violence's Coaching Boys Into Men (CBIM) programme, by Centres for Disease Control and Prevention (CDC), which teaches high-school athletes healthy and respectful behaviour to prevent GBV. CBIM teaches young athlete men that violence does not equal strength. Another area that does not receive enough attention, research and resources is the rehabilitation of sex offenders. There is not enough research on the different sex offender intervention programmes and their effectiveness on young and/or adult offenders; the 'Good Lives Model' and/or Standard Relapse Prevention Programme, amongst other models, especially amongst young offenders [20]. Investment in research in the effectiveness of each model per age group will ensure that research informs evidence-based solutions.

#### **4. Response to sexual and gender-based violence and femicide: Thuthuzela Care Centres case study**

'Violence against women (in South Africa) is a social problem produced by choices made by corporations, governments, politicians, faith-based organisations, and individuals… It is not a crisis out of our control but a social condition that can be interrupted through deliberate efforts' [21].

According to the World Population Review [22], in 2010, South Africa had the highest rate of rape in the world at 132.4 incidents per 100,000 people; this decreased to 72.1 in 2019–2020. While this is still in the top 3 in the world, it is going in the right direction. This could be a real decline, but it could also be a sign of decrease in reporting due to various factors, including lack of trust in the criminal justice system [23]. The South African government has promulgated progressive laws to address gender equity in general and gender and domestic violence specifically; however, the numbers remain very high. Civil society has been instrumental in driving the progressive laws and initiatives to combat SGVBF. One of these coalitions is the Shukumisa Coalition (Shukumisa means shake up in Nguni language), which has over 60 organisations whose focus is fighting sexual violence against women and children. In 2018, during the month of August, thousands of women and gender non-conforming people (GNC) took to the streets of South Africa under the banner of the Total Shutdown Movement (TTS), demanding intervention by the government and businesses to end the high rates of gender-based violence (GBV) against women and GNC people. This led to a National Summit on Gender Based Violence and Femicide which brought together the government, the Total Shutdown Movement and various civil society organisations; the summit concluded with the signing of a declaration that the government, businesses, labour and civil society would collaborate to conceptualise, drive and implement concrete measures to eradicate gender-based violence and femicide [24]. The National Strategic Plan (NSP) for GBVF was a product of this collaboration; see **Figure 1** below.

#### **Figure 1.**

*National Strategic Plan for GBVF. Source: www.dsd.gov.za.*

*A Case Study on Transdisciplinary Approach to Eradicating Sexual Violence: Thuthuzela Care… DOI: http://dx.doi.org/10.5772/intechopen.110836*

The NSP is a multi-sectoral, coherent strategic policy and programming framework developed to strengthen a coordinated national response to the crisis of GBVF by the Government of South Africa and the country. The six pillars require a multisectoral and transdisciplinary coordination of effort to eradicate SGBVF. The NSP follows many different initiatives by the government to curb the scourge of GBVF. One of these was the establishment of a special unit, the Sexual Offences and Community Unit, in 1999 under the National Prosecuting Authority (NPA) within the SA government's Department of Justice. Thuthuzela Care Centres are an initiative under SOCA.

#### **4.1 Sexual Offences and Community Unit (SOCA): Thuthuzela Care Centres**

The Sexual Offences and Community Unit (SOCA) is responsible for the SGBVF mandate of the NPA. SOCA is led by a special director. The responsibilities of the directorate, as shared in the South African government official website, include1 :

Executing its mandate to develop best practices and policies in the reduction of gender-based violence, the SOCA unit introduced Thuthuzela Care Centres (TCCs) in 2006. Thuthuzela means to comfort in one of the South African languages, isiXhosa.  The mandate has since expanded to include all victims of GBV. This initiative is one example of a transdisciplinary approach in solving national challenges. Each centre is hosted within a health institution, hospital or clinic and is linked to one or more police stations. It is a collaboration between the NPA (Department of Justice), Department of Health, Department of Social Development, Treasury Department and non-governmental organisations (NGOs) who work with social workers to offer counselling.

1 National Strategic Plan On Gender-Based Violence & Femicide Accessed on 18 September 2022 from https://www.justice.gov.za/vg/gbv/NSP-GBVF-FINAL-DOC-04-05.pdf

#### **4.2 Sexual Offences Courts (SOCs)**

The Sexual Offences Courts are dedicated to sexual violence cases; they are victim centred through provision of a victim-friendly place, CCTV equipment (for victims to testify in camera), a special victim testimony room and a private waiting room. Regarding human resources, each court should have a presiding officer, two prosecutors, an intermediary, an interpreter, a designated court clerk, a designated social worker, a legal aid practitioner and an official to help with court preparation, including provision of counselling services by social workers [25]. The first sexual offences court was opened in Wynberg, Cape Town (SA), in 1993. The conviction rate was up to 80%, which was very high compared to 'general' courts (4–6% at the time for similar crimes). Around 2005, there were about 74 SOCs in the country. Due to various reasons, including funding, there was a moratorium on the SOCs. 'In 2020, section 55A of the Criminal Law (Sexual Offences and Related Matters) Amendment Act was signed into operation meaning that for the first time Sexual Offences Courts are being established in accordance with a statute', explained Deputy Minister of the Department of Justice, [26]. He continued to explain that the regulations relating to section 55A stipulate support that should be given in section 55A SOCs, namely, court support, court preparation, emotional containment, trauma debriefing, counselling, private testifying service, intermediary services and information services. Sexual Offences Courts work closely with TCCs to ensure that a victim-centred and holistic integrated service is being provided to victims.

#### **4.3 The stepwise approach at TCCs**

**T**he one-stop shops are well coordinated through collaboration across disciplines. The layout design enables a stepwise approach, which ensures efficiency and protection of the victim from the time she walks into the centre. Below are the different steps that victims go through and the department responsible for each step:

*A Case Study on Transdisciplinary Approach to Eradicating Sexual Violence: Thuthuzela Care… DOI: http://dx.doi.org/10.5772/intechopen.110836*

This holistic approach helps to increase the conviction rate by building a case ready for successful prosecution, offering psychosocial support to victims/survivors and reducing the cycle times of these cases from reporting to finalisation. The current sites for TCCs were identified based on various criteria, including the volume of sexual offence cases reported at the local SAPS (police stations); the number of sexual offence cases dealt with at the local court/s; availability of space at the local hospital; presence of SAPS Family Violence, Child Protection and Sexual Offences (FCS) unit; availability of non-governmental services for victims and stakeholder buy-in (**Figure 2**).

According to the South African government website, as at September 2022, the number of TCCs was 581 . Though the funding of the TCCs is from the government,

the private sector is encouraged and is starting to assist in the building of more TCCs, including using private hospital sites, provided the site is linked to a police station. Support from the private sector includes donations of equipment. Working with the Gender Based Violence & Femicide Response Fund, the Minerals Council of South Africa and the custodian of TCCs, the NPA, signed a memorandum of agreement to work together to support the Thuthuzela Care Centres for victims of gender-based violence, with a particular focus on mining communities and/or labour-sending areas.2

### **4.4 Roles and responsibilities of different departments**

The roles and responsibilities of the different departments in the TCC collaboration are as follows [28]:

### *4.4.1 National prosecuting authority under department of justice*

### *4.4.2 Department of health*

#### *4.4.3 South African police services*

2 Ref. [27].

*A Case Study on Transdisciplinary Approach to Eradicating Sexual Violence: Thuthuzela Care… DOI: http://dx.doi.org/10.5772/intechopen.110836*

#### *4.4.4 NGOs*

#### *4.4.5 Department of social development*

Appointment of social workers and counsellors (**Figure 3**).

#### **4.5 Success factors of the Thuthuzela Care Centres**

The success of the TCC model lies on at least five pillars: victim-centred, courtdirected, multidisciplinary approach, policies that empower different service providers in tackling SGBV and successful coordination of all services amongst different departments.

#### *4.5.1 Victim/survivor-centred*

Services are tailored to the victim's needs, and secondary victimisation is reduced by creating a victim-friendly environment, safe and conducive to reporting and retention. Trained professional personnel empower the victim through psychosocial support and legal preparation for the court cases. Trust is built due to clear and accurate feedback at all stages of the journey for the victim.

#### *4.5.2 Court-directed*

Offender accountability is ensured by using a systematic approach through trained specialised personnel. This includes securing physical and forensic evidence by trained personnel from the victim/survivor and focused, prosecutor-guided investigation. Having specialised courts linked to the TCCs ensures speedy and seamless

**Figure 3.** *TCC sites in South Africa as of February 2022. Source: www.justice.gov.za.*

prosecution process. There are NGOs that specialise in training victims on how the legal system works in preparation for the court case.

#### *4.5.3 Multidisciplinary approach*

No one department can solve the complex challenge of SGBV. Cooperation amongst role players, from health and forensic workers, police, treasury, correctional services, designated civil society organisations, social workers and counsellors to prosecutors, is key for successful prosecution and empowerment of the survivors. Ensuring accountability of each stakeholder with shared objectives and effective leadership is required for the multidisciplinary approach to be effective.

The direct link between the TCC, the SAPS FCS, the hospital and sexual offence court, where the matter will be heard, is a seamless transdisciplinary approach. Linking TCCs to GBVF hotspots ensures easy access for victims where the need is the highest.

**Policies and Regulatory Framework** that empower stakeholders together with **leadership** in coordinating a seamless service provision play an important role in the attempt to prevent and eradicate SGBVF.

#### **4.6 Impact of Thuthuzela Care Centres**

Data from the past 5 years show that cases from the TCCs have attracted more severe gaol sentences on the offence of rape specifically in courts, with 15 to 18% of cases getting life imprisonment for perpetrators. Public awareness campaigns are run by TCCs (designed by SOCA) to empower surrounding communities. The raised awareness has increased reporting levels, though there is still a long way to go. South Africa has one of the highest HIV/AIDS cases in the world. Provision of post-exposure prophylaxis (PEP) by TCCs forms a critical component of reducing the transmission of HIV/AIDS; thus, TCCs are a crucial component in the fight to reduce the transmission of HIV/AIDS. This service attracts victims even if they have no intention of opening a case against a perpetrator.

*A Case Study on Transdisciplinary Approach to Eradicating Sexual Violence: Thuthuzela Care… DOI: http://dx.doi.org/10.5772/intechopen.110836*

#### **4.7 Challenges**

The location of TCCs is partly determined by rape hotspots as reported by the police stations. The way the hotspots are selected is challenged by scholars. Between April 2008 and March 2009, 12,093 women in Gauteng, or 0.3% of the province's adult female population, reported an assault by an intimate partner to the police; by contrast, during the same period, 18.1% of women in the province reported an experience of violence at the hands of intimate male partners to researchers [23]. Lack of trust in the criminal justice system maybe one of the reasons for underreporting at the police station. The second challenge with the accuracy of the identification of hotspots is the system used by the police of ranking informed only by the total number of cases reported, which produces lists with a predominance of stations serving densely populated areas, as opposed to looking at the number of crimes relative to the size of the population. The inaccuracy of reporting leads to misallocation of resources, including the TCCs. The 'misreporting' leads to loss of resource allocation where the need is high.

The ideal design for TCCs has a separate entrance for perpetrators, to ensure protection of victims. However, a compliance audit and gap analysis report showed that only 52% of TCCs have a separate entrance for perpetrators [28]. This could have improved over the past 5 years. The same report acknowledges that the majority of TCCs operate according to the TCC Blueprint; half the TCCs offered more services than those prescribed, like age estimation, shelter offering and DNA testing of suspects. The structure of the facilities is key to ensure a seamless service delivery. Lack of adequate fund allocation to the TCCs programme is critical in ensuring that the facilities, the equipment used and the personnel are fit for the purpose. Funding cannot be overemphasised for the success of this programme.

Having adequate number of trained personnel in the different steps of the TCC Blueprint determines the success of the programme. However, not all personnel are available 24/7, which requires victims to come back for part of the service during office hours. Transport is another issue; transport by the SAPS and/or by the victim is another challenge that needs to be addressed. This has a major impact on visits to court and follow-up psychosocial-support visits by victims, especially low-income/unemployed victims who do not have their own transport, who happen to be in the majority.

There is a need for a sustainable, consistent and stable funding environment to ensure that the necessary services can be delivered at all TCCs [28]. Funding, especially of NGOs, is one of the main challenges to service delivery.

Coordination amongst departments is not always at the correct level to ensure that the service is efficient. Enforcement of the progressive laws in the country is lacking in a few areas of the criminal justice system, which hinders successful and timeous conclusion of cases.

There are not enough TCCs to address the challenge of GBV. The country has 155 Family Violence, Child Protection and Sexual Violence SAPS units, with only 57 TCCs. Ideally, there should be one TCC for each unit.

#### **5. Conclusion**

South Africa has a history, during apartheid days, of condoning violence against most of the population along racial and gender lines. The past apartheid laws were dehumanising to the majority and broke family units. These challenges were not

adequately acknowledged nor addressed when the new dispensation was ushered. Patriarchy and masculine toxicity normalise all forms of violence against women and children. Achieving social cohesion, one of the ingredients to SGBVF prevention (Pillar 2 of the NSP-GBVF), is an important and common thread that needs to override and bind all interventions. Progressive laws need to be well implemented by the responsible stakeholders to achieve what they are set for. Lack of accountability and leadership (Pillar 1 of the NSP-GBVF) underpins all success in tackling big and small challenges. Justice (Pillar 3 of the NSP-GBVF) brings back trust in the criminal justice system and plays a role in preventing repeat offences. Research (Pillar 6 of the NSP-GBVF) to understand root causes and understand what works and what does not helps in the design of evidence-based solutions. Lastly, achieving economic equality across genders (Pillar 5 of the NSP-GBVF) empowers women to leave toxic relationships and helps them to value their worth in society. All the above are ingredients of a progressive and cohesive nation that has the potential to prosper. Leadership and accountability of each citizen and leaders across all sectors of society cannot be underestimated. The transdisciplinary approach that delivered the comprehensive NSP for GBVF was a good start to find solutions. However, like any plan, effective implementation is what determines success.

Thuthuzela Care Centres are the most cohesive and transdisciplinary intervention to date that seek to prevent and eradicate sexual and gender-based violence & femicide. Accountability by each stakeholder from the opening of the case to its conclusion will improve the results and edge the country closer to gender-based violence and femicide eradication. The country requires more partnerships and transdisciplinary approaches to tackle national challenges. The transdisciplinary approach of the TCC model can be that required solution to the sexual and gender-based violence and femicide crisis in the country. It will take leadership and accountability by all parties to achieve success.

### **Author details**

Judy Dlamini University of the Witwatersrand, South Africa

\*Address all correspondence to<EMAIL_ADDRESS>
© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*A Case Study on Transdisciplinary Approach to Eradicating Sexual Violence: Thuthuzela Care… DOI: http://dx.doi.org/10.5772/intechopen.110836*

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#### **Chapter 6**

## If I Didn't Laugh, I'd Cry: Humor as a Coping Strategy for Adult Survivors of Childhood Sexual Abuse

*Kathleen Monahan*

#### **Abstract**

This paper examines the coping strategy of humor presented by eight adult women aged 26 through 61 in a small clinical practice setting. Each woman had been sexually abused by a variety of family members during childhood. They were seeking therapy for life-phase issues (e.g., divorce, retirement, marital problems, parent/child issues). The reemergence of sexual violence memories and the ways in which these women used humor as a coping strategy to alleviate the effects of childhood sexual abuse (CSA) are presented.

**Keywords:** childhood sexual abuse, trauma, coping, recovery, humor

#### **1. Introduction**

The search for meaning and adaptive coping strategies regarding traumatic events [1, 2] extends to survivors of childhood sexual abuse (CSA) [3–8]. CSA can create psychological and health difficulties that span the life course, disrupting a positive worldview, coping abilities, and adaptive strategies [3, 5–7, 9, 10]. A significant task for survivors is assigning meaning to the traumatic event and developing a philosophy that assists in developing coping strategies that promote healing and recovery [4].

Types of adaptive coping strategies have been a focus of research and treatment for CSA survivors [3–5, 11–14]. Additionally, posttraumatic growth (PTG), assisting the survivor in healing and creating a sense of agency, has been an important area of focus [15].

Studies examining the search for meaning and reframing thinking and coping have furthered our understanding of the recovery process. Yet, the critical survival strategy of humor has been absent in the CSA literature for adult survivors. Do CSA survivors use humor as a method of coping with this traumatic event, and if so, in what ways do they use humor? This chapter presents the treatment issues presented in a small clinical sample of sexual abuse survivors utilizing humor as a coping strategy.

This coping strategy was reported to be foundational as part of their positive recovery. The coping styles of adult CSA survivors employed playfulness and humor and thus assisted in helping them to grow and flourish. Humor as a coping strategy is underrated and not commonly presented as a viable intervention in treatment and recovery. To that end, women who have experienced CSA and their views about humor and its usage to reframe and assuage traumatic events are presented.

#### **2. Incidence and prevalence of childhood sexual abuse**

One in five women and one in 13 men report sexual abuse as a child. However, the numbers for male victimization are vastly underreported [16]. Worldwide rates indicate that forced sexual contact occurs for 120 million girls and women under 20 [17]. While our knowledge regarding this crime has grown over the past three decades, childhood sexual abuse remains at epidemic proportions in the United States [5, 18, 19].

 Teenage pregnancy [23] and eating disorders [24] are also adverse outcomes of CSA. More complex disorders such as dissociative disorders and posttraumatic stress disorder (PTSD) [6, 13, 25–29] are significant in this population. Physical and oral health issues are also reported health outcomes of CSA for adult survivors [6, 25–27, 30]. It is significant to note that many of these women will be at risk for sexual revictimization [31, 32].

Disclosure by CSA survivors has been difficult for a variety of reasons such as shame, fear of disbelief, and lack of support [33]. Recent communication changes such as digital platforms, social media, and online communities have increased disclosure in a public forum while increasing social support [34]. This public dialog by CSA survivors also creates a pathway to increase our knowledge regarding the prevalence and experiences of individuals who have been sexually abused during childhood [35].

#### **3. Coping with CSA**

Coping strategies, derived from belief systems about the event, and views about how the world works have been an area of research interest for quite some time [7, 14, 36]. Making sense of sexual abuse victimization can be a life-long quest that embodies constant questioning and anxiety without resolution [7].

The ability to cope with traumatic events has focused on managing the demands of stressful and traumatic events while categorizing the event itself and reactions to it [13, 37, 38]. Walsh et al. [8] define coping as "…a range of diverse cognitions and behaviors used to manage the internal and external demands of a stressful or threatening situation" (p. 3).

 For instance, CSA survivors can employ a range of coping strategies such as selfblame, avoidance, and cognitive restructuring. Characterological self-blame (I am the reason this happened) and behavioral self-blame (my behavior – which I can change – is the reason this happened) have been studied with a variety of populations [40, 41]. Behavioral self-blame has been viewed as a better strategy because behavior is changeable ("I won't walk in that neighborhood again"). However, several authors have challenged this notion, positing that all kinds of self-blame, despite its use as an adaptive strategy, have negative consequences [42–45].

*If I Didn't Laugh, I'd Cry: Humor as a Coping Strategy for Adult Survivors of Childhood Sexual… DOI: http://dx.doi.org/10.5772/intechopen.113064*

Other coping strategies such as avoidance, cognitive restructuring, or the way one thinks about events that are happening, have happened, or will happen, can also have adverse outcomes. Avoidant strategies, for instance, attempt to avoid any interaction with the abuser and may impact normal attachment development [14, 18, 20, 31, 46].

Several models postulate why some victims will experience negative sequelae while others develop coping skills that help them organize positive rationales and philosophies about the experience and life in general [12, 47–49].  Barker-Collo and Read [39] state.

*The findings of both Barker-Collo et al. [50] and Shapiro and Levendosky [48] point toward the ability of complex mediational models to account for significant proportions of individual variations in symptom presentation among abuse survivors (p 104).*

The author's go on to cite Draucker's [12] findings.

*At an initial level, traumatic sexualization, stigmatization, and feelings of powerlessness and betrayal develop during childhood as a result of abuse. Two of these factors, feelings of powerlessness and stigmatization, significantly affected the three outcome variables: social introversion, interpersonal victimization, and guilt. These were further affected by two mediating tasks: the search for meaning/ understanding of the abuse and its outcomes and attaining a sense of mastery (p. 106).*

Mediating (intervening) and moderating (tempering) variables influence coping ability [8]. These include the type of abuse that occurred and by whom, the severity of the abuse, the frequency and duration of the abuse, and support systems that could and did not intervene [8]. In addition, temperament, familial environments, and organizational responses such as schools, Family courts, and the legal system influence coping styles [4].

Until recently, the CSA field has focused on debilitating and harmful outcomes for survivors [51–54] and how to ameliorate them. Understanding this aspect for the CSA survivor is critical to healing and recovery. Newer models, however, focus on resilience, posttraumatic growth, and positive cognitions and coping strategies employed by trauma survivors [15, 51, 53, 55, 56]. More recent research has identified that CSA survivors can develop coping strategies that assist them in leading productive lives [4]. Graham et al. [4] identified several critical factors in coping strategies that promote successful outcomes: reframing the event/s, taking control of the traumatic memories, and thinking about it differently.

#### **4. Humor and trauma**

Humor has been viewed as a way of coping since time immemorial [57, 58]. Humor increases the quality of life and is an effective tool in dealing with stress and health issues [57, 59–62]. The benefits of laughter – direct physical benefits – and humor, which indirectly improves physical status and mediates mood and cognition [63, 64] are now widely recognized by a variety of mental health disciplines [15, 65–70]. Positive humor and playfulness improve positive self-concept [71] and overall happiness [60, 72].

Humor has been studied with a diverse set of trauma populations, including veterans, individuals who experience severe medical conditions, and older adults [73, 74]. As a result, different humor interventions have been developed, such as Laugh Yoga and Medical clowning [75].

The idea or notion that humor can be introduced or utilized in the throes of trauma presents an oxymoron. On the one hand, the person is cognitively and emotionally challenged in dealing with a traumatic event and suffering; at the same time, they are cognitively and emotionally challenged with a visual or auditory depiction of something playful or humorous [61].

Yet, humor and playfulness serve dual primary purposes: to distract and provide a sense of hope. The first aspect, distraction from painful affect and cognition, creates cognitive dissonance, the premise that an individual cannot hold two competing thoughts simultaneously [21, 64, 76]. On the other hand, laughter creates a sense of relief – usually from stress – both mentally and physically, thus giving way to a sense of hope.

Several authors have addressed the benefits of incorporating humor and playfulness within psychotherapeutic treatment and how to do so [21, 61, 68, 77, 78]. An individual's sense of humor is an important aspect of coping, and the clinician needs to be mindful of both the client's and their own "Humor Quotient" [79].

While the field has been slow to adopt the importance of humor in the treating room the use of humor either by the client or the clinician is now viewed as beneficial [4, 80, 81]. Several issues such as timing, the purpose of humor within the session, the type of humor, cultural differences, gender, language, and client diagnosis [60] should be considered when incorporating humor as part of the treatment process, either by the clinician or the client.

#### **5. The clinical sample**

This chapter examines how humor is utilized as a coping strategy in a small, clinical practice setting by eight women aged 22 through 61. These women had been sexually abused during childhood and adolescence by various family members (father, grandfather, stepfather, brother, uncle, and mother's boyfriend). It should be noted that none of these women presented with diagnoses that consisted of personality disorders or the range of dissociative disorders. Initial treatment centered on significant life-phase issues, including marital issues, remarriage, divorce, parent/child issues, and children going to college and retirement. During treatment, previous memories of sexual abuse were triggered and emerged as a focus of attention. The CSA consisted of rape, sodomy, and fondling. Four women reported that the abuse was further traumatizing by the abuser's constant statements that the cause of the abuse rested with her ("You always tempt me to behave this way"). All of these women had previously been in treatment for their sexual abuse issues before entering treatment with this author. The women's current developmental crises had triggered previous abuse memories and therefore cases for examination were selected for their use of humor and playfulness as coping strategies in a) dealing with the sexual abuse and b) recovery responses were part of their treatment discussion. The themes regarding their use of humor as a coping strategy are included here. While the following comments and data are anecdotal, they nonetheless represent a previously unexamined area of coping for this population. Women whose comments are utilized in this paper gave permission for their use.

### **6. Different ways CSA survivors utilize humor**

#### **6.1 Vulnerability and powerlessness**

Several CSA survivors reported feeling vulnerable and powerless during childhood, adolescence, and young adulthood due to the abuse, and humor was utilized as a tool. They reported that being funny – comedic- served to keep the abuser at bay – even for a little while. Additionally, their sense of humor assuaged their sense of powerlessness.

*I believe that you have a choice: you can sit and cry about what happened or you can make up your mind that you are going to have a good life and not let the bastard win. I make sure I laugh all the time. It's like that old saying: If I did not laugh, I'd cry.*

*I had the uncanny ability - and I still do – of delivering very funny one-liners. I was very young when I realized that I could go up or down. I could make my funniness sharp, almost sarcastic, or tone it down. For me, it was a powerful tool, and it reduced my feeling of being isolated and fearful, even in school. Sometimes, not always, it worked to keep him away because he never wanted to be a target of my humor.*

*I was known as the funny kid. Now I'm known as the funny adult. But as a kid my stepfather, at first, thought it was great that I was so funny. Except when he abused me, the next day I was so angry that I would be super funny - at his expense - whenever I could. Of course, I paid the price but hey, I felt that I won. I got my punches in.*

The clinician should note, however, that utilizing humor to point out vulnerability or powerlessness should be a focus of attention, drawing light on the fact that while the client is presenting situations or feelings about vulnerability in a funny way, it also highlights the pain and sorrow of victimhood.

#### **6.2 Distracting in playful ways**

Humor can be described as a distraction from painful events or memories has always been recognized as an important foundational aspect in the use of humor. Several women identified the use of funny movies, television series or jokes as a useful coping mechanism that distracts from painful memories or emotions.

*No matter how I tried to avoid him, my father used to get me alone and sexually assault me. He would always try to isolate me. This went on for years. The only relief I got were two things. I would take my dog outside and we would run and wrestle and play for hours and I would feel like I did not have to worry about anything when we played. The other was watching The Three Stooges which would make me laugh. When I was laughing, I felt like I could forget everything. I have kept this idea my whole life…laughing has always helped me.*

*I think I'm an optimistic person.  The laughing helps me not think about how bad things were.*

*Somehow when I laughed, I always felt that I would survive this. As bad as it would get, laughing made me feel that someday I would be alright, that there was hope. It still does.*

*When I think of the abuse, I tell myself that at least I'm not a sick person like he is. I decide that I'm going to be happy and then I'll make sure that I find some way to laugh or have fun.*

#### **6.3 Life is absurd**

Thinking differently about the CSA has been identified as one way to develop a coping strategy that minimizes negative emotions and thought processes [4]. Several women reported their use of humor to be more reserved, i.e., in their "head," using humor or absurdity as an approach to thinking differently about the abuse itself, the offender, or life in general. Part of this humor approach involves the notion that if something is ridiculous, how can it be threatening [21, 82].

 It was so ridiculous, so stupid, that it helped me to see him as an absurd person and I would burst out laughing. It ultimately belittled his power over me. I have used this type of visualization, ones that would make me laugh at the absurd, in difficult situations.*

#### **7. Humor, jesting, and playfulness in the treating room with CSA survivors**

Clinical work addressing trauma is generally phase-based, tailored to symptom presentation [83], and incorporates practice elements that create an environment for healing. A host of symptom reduction interventions such as emotional regulation, cognitive restructuring, stress management, and improving interpersonal skills are employed to create safety and set the stage for change [61, 83]. "Second line" strategies are mindfulness and meditation strategies [64, 83]. Additionally, understanding the support system available and the cultural context are vital to successful treatment [61, 84].

Humor, jesting and playfulness, although not stand-alone interventions, are generally not considered within the context of trauma treatment despite the potential to increase the therapeutic alliance while bolstering a sense of safety [61, 73, 85]. Garrick [73] reminds us, "…our neurological responses to laughter and general happiness, as well as the nature of humor, represents an asset to therapy" (p. 171). The therapists' style and sense of humor are also significant factors in determining the employment and usefulness of playfulness and humor in the treating room [78]. It should be noted however, that humor should be a well-thought-out consideration and not just a random, tongue-in-cheek intervention utilized with trauma survivors.

Important considerations appear below.

#### **8. Cautions and considerations on the use of humor with CSA survivors**

#### **8.1 The clients use of humor**

While safety and the development of rapport are essential to establish the foundation of conducting trauma-responsive work, attunement between the clinician and the client should also be established in terms of sense of humor. For example, a clinician who has a strong sense of humor matched with a client who has a low sense

#### *If I Didn't Laugh, I'd Cry: Humor as a Coping Strategy for Adult Survivors of Childhood Sexual… DOI: http://dx.doi.org/10.5772/intechopen.113064*

of humor should use caution in employing humor in the treating room, in general, but when trauma is the topic, in particular.

Some authors have identified clients' use of humor in the treatment process as undermining the serious nature of therapy [86, 87], while others have stated that it is a defense that deflects from issues at hand [88, 89].

Timing and phase of treatment are also important considerations when employing humor and playfulness in the treatment process. The clinician must assess if the use of humor by the client is utilized to deflect painful and difficult conversations, delay trauma processing, minimize negative sequelae, or keep the therapeutic alliance in a static condition so that further work cannot commence. These are important variables that need to be applied when considering the use of humor in the treating room. These aspects needs to be evaluated and addressed with the client so that the use of humor and playfulness is clearly understood.

#### **8.2 Humor as a defense mechanism**

Sexual violence such as CSA "represents profound violations of an individual's body and emotions" ([68], p. 1). Given this fact, a survivor may have been likely to employ defense mechanisms that assisted in adapting to daily life, especially if the abuse is ongoing; humor may have been part of the equation. Additionally, humor may be "employed" as a defense mechanism to thwart discussions that address serious or traumatic material. Approaching this content with empathy is fundamental, with the additional caveat of understanding how and why this defense is being utilized. The clinician may need to adapt their use of humor to the changing treatment issues and explore with the client how their use of humor may be changing. Several questions should be employed such as is humor part of denial regarding the abuse or significant impact? Is humor utilized as a coping strategy in particular situations that "benefit" the client? Is it a way to delay discussions about the abuse? Is humor used in a self-denigrating manner?

Trauma-responsive work entails the foundational approach of strength-based interventions [90]. While clients may employ a coping strategy that veils anger and low self-esteem behind self-demeaning, denigrating humor, it's the clinician's task to address how that may impede positive self-worth, posttraumatic growth, and the recovery process overall. The overarching component is how and why a client is using humor, the timing of its use, and the rationale for how the clinician responds to this humor usage. Assisting the client in understanding how the use of humor helps or hurts processing the sexual violence is just one aspect in the arsenal of healing and recovery.

Although not the topic of this chapter, the clinician will want to pay close attention to those individuals who present with personality disorders and/or the range of dissociative disorders and the use of humor and playfulness. As mentioned, the women in this chapter are from a general group of CSA survivors separate from those individuals who experience personality disorders and/or the range of dissociative disorders. Dissociative CSA clients may rely on separate personalities who use humor to deflect painful memories at the expense of the whole personality. Caution should be exercised by the clinician, who needs to be attuned to the client's use of and response to humor throughout the course of treatment.

#### **8.3 The clinician's use of humor**

Working with individuals who have been sexually violated, particularly during childhood, is difficult work at best. This type of clinical work has the potential to

stir strong emotions and reactions within the clinician, and some even suggest that trauma work can be considered an "occupational hazard" [91, 92].

The clinicians' prior experiences, countertransferential reactions, and reasoning for the use of humor needs to be examined, particularly how it will enhance treatment and assist the client in the recovery process. How the clinician's "agenda" may enhance and impede treatment needs to be examined regarding humor, just as any intervention in the therapeutic context. An example of both the client's use of humor and the clinician's countertransferential reactions appears below.

 Viewed as an optimistic child, she was outgoing and funny. She entered treatment to address her grief over a failed marriage and her inability to maintain employment. She viewed her comedic persona as a gift and fancied becoming a comedy writer and stand-up comic.

However, her constant comic presentation in session thwarted addressing her presenting issues, yet she would infer a great deal of anger toward men and her previous traumatic sexual abuse.

Sessions centered on how her deflection through "entertaining" the therapist through laughter did not assist her recovery but rather kept us from addressing her issues. This author shared with S. that the author's love of laughter made her hilarious presentations attractive but kept us from the serious discussions that were essential to her recovery. In one of these discussions we addressed her use of humor as "the shield" that not only protected her from serious discussions but kept people at a distance through the laughter. We also addressed that while she was a naturally funny person, her constant humorous presentation may not have served her well in other situations such as employment and previous treatment. The painful discussions that humor masked her trauma and anguish were indeed difficult, but she was able to reflect on her use of humor, her timing, and the humor's goal. While the intent was not to extinguish her use of humor it was more to understand its purpose.

As for the clinician's part, this author found S. very funny and loved the laughter that she created but recognized that we were not getting "work" done. The realization that the therapeutic work at hand was difficult, accompanied by "why can't I have a chance to laugh?" was part of the hard task of trauma work. Supervision assisted in analyzing this quagmire and provided this author with the opportunity to resolve the issues that then helped to move S.'s treatment forward.

These cautions notwithstanding, the client's use of humor can create a sense of control and empowerment while also distracting from obsessive thoughts and negative self-talk [59, 61, 73]. When people play, they are not scanning for danger and, thus, not feeling vulnerable [21]. Creating enough safety that assists a person to feel open and free enough to play, e.g., vulnerable, creates an environment where growth is possible. While one may have a good or strong sense of humor, it is important to understand the timing and the employment of empathy while using humor in a therapeutic context.

#### **9. Discussion**

Using humor in therapy is beneficial to the therapeutic encounter [21, 68, 77, 78]. However, it is not clear how often and in what ways CSA survivors utilize humor and playfulness as a coping strategy that promotes their recovery process. Anecdotal, clinical information, and information emerging from social media suggests that the

#### *If I Didn't Laugh, I'd Cry: Humor as a Coping Strategy for Adult Survivors of Childhood Sexual… DOI: http://dx.doi.org/10.5772/intechopen.113064*

old adage: "If I didn't laugh, I'd cry," is valid for this population. Utilizing humor deflects the tragic and traumatizing aspects of a childhood filled with violent, sexualized brutalization. These women discussed the issues of vulnerability, powerlessness, and fear that were moderated through humor and playfulness. Several CSA survivors reported feeling powerful when viewing the abuser and/or situation differently, such as absurd situations.

As demonstrated with this small cohort, a sense of hope and resilience is imbued with the use of humor and playfulness [60]. The clinician needs to understand the importance of this coping strategy in the therapeutic context, particularly the issues of sensitivity and timing. Other important issues are to address the client's use of sarcastic or demeaning humor and gently challenge when they do [60].

Humor and playfulness can assist in continually building the therapeutic alliance [21, 61, 68, 77, 78]. Clinicians should carefully monitor countertransferential issues and contraindications of humor in the therapeutic context [60].

Assessing if humor is a thought-out strategy, part of the individual's temperament or resilience skills, or a combination of variables will assist in understanding humor as a coping strategy. Moreover, how humor enhances or impedes – or both – positive outcomes furthers our understanding. Further research will assist in developing therapeutic techniques and approaches for this population, just as the medical clowning field and other humor researchers have developed approaches that have increased our awareness of humor as a vital tool in recovery.

This small clinical sample is an exploration of how humor and playfulness are utilized as a coping strategy by CSA survivors; while it cannot be extrapolated to the general population of CSA survivors, it warrants further investigation. Exploration and enhancement of humor in the therapeutic encounter add to the repertoire of positive coping strategies of CSA survivors. Further investigation of this coping strategy will increase clinical awareness and the arsenal to improve the recovery processes of CSA survivors.

Future research will also need to investigate how humor is utilized by CSA survivors with personality disorders and/or the range of dissociate disorders. How humor is addressed for CSA survivors by the clinician, humor utilization at different stages of treatment (both clinician and client) and contraindications on the use of humor still need to be researched.

#### **10. Conclusion**

This chapter presented the use of humor and playfulness as a coping strategy by a small group of CSA survivors in therapy. While humor is seen as a productive and helpful way to reduce stress and improve mood, it has not been widely viewed as a coping strategy in the recovery process of childhood sexual abuse. Clinicians' attention to how humor is being utilized within the treatment setting and as a coping strategy for CSA recovery will assist in understanding the utility of this approach. Clinicians will need to understand the timing of humor utilization, self-denigrating humor, humor as a defense, and countertransferential reactions when using humor with this population. Research is needed to understand how humor is utilized by both CSA clients and clinicians, particularly with populations with personality disorders and a range of dissociative disorders. Understanding the use of humor as a coping strategy in trauma treatment has the potential to improve the therapeutic alliance and recovery processes for CSA survivors.

#### **Author details**

Kathleen Monahan School of Social Welfare, Stony Brook University, Stony Brook, New York, USA

\*Address all correspondence to<EMAIL_ADDRESS>
© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*If I Didn't Laugh, I'd Cry: Humor as a Coping Strategy for Adult Survivors of Childhood Sexual… DOI: http://dx.doi.org/10.5772/intechopen.113064*

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### *Edited by Kathleen Monahan*

Sexual violence is a multifaceted crime and a global health problem. It is a crime that can happen to anyone, including young and old, male and female, rich and poor. Sexual violence persists due to several variables, including abuse history and a society's tolerance of the crime. Additionally, belief systems, cultural norms, and legal systems create environments that allow abusers to escape detection. This book addresses sexual violence myths, belief systems, and the media's role in perpetuating sexual violence. It also examines the role of social media in facilitating sexual crimes, particularly sex trafficking. Finally, this book examines the work of community stakeholders in addressing and treating individuals who have been sexually victimized and the coping mechanisms of sexually traumatized adult women.

Published in London, UK © 2024 IntechOpen © Asha Natasha / iStock

Sexual Violence - Issues in Prevention, Treatment, and Policy

Sexual Violence

Issues in Prevention, Treatment, and Policy

*Edited by Kathleen Monahan*


**5. Supportive care**

Supportive care describes the multidisciplinary care required to fulfill the needs of the patient and family in order to meet the physical, informational, psychosocial, emotional, practical, and spiritual needs during all phases of their cancer care [53]. The treatment of pediatric brain and spinal cord tumors is complex and every family is different, with variable needs throughout treatment. This requires a collaborative and multidisciplinary health-care team to effectively assess and address the required supportive care early during the stage of diagnosis or initial therapy [53, 54].

The supportive care needs of pediatric patients and their families include the physical (physiotherapy, occupational therapy, speech pathology, dietician, medical, pharmacy), education/informational (often met by nursing and medical team members), as well as psychosocial (social work, psychology, child life, psychiatry). It is important to reassure the family that the intense emotional reactions (including fear, powerlessness, denial, guilt, sadness, anger, confusion, anxiety, and depression) are normal responses to the child's illness and that the team is there to support and not judge them. Complete family assessment including psychosocial and practical resources, employment, socioeconomic status, as well as an assessment of marital-parental and sibling relationships should be studied and managed [54]. Misunderstanding may influence care [54].

#### **5.1. Informational needs**

Good communication by the health-care team, repetition of information, opportunities to ask questions, and written materials are important for assisting families. Gaining information about their child's condition allows parents to feel some control over the situation and regain some peace of mind. Psychosocial providers can assist families to manage feelings of infor‐ mation overload and problem solving according to the demands.

Parents may require guidance from the team regarding how and when to talk to their children, to do it so honestly and at an age-appropriate level, yet in a way that decreases anxiety and increases trust in the treatment process and team.

Normalizing activities as much as possible can be of great help in restoring a sense of safety and normalcy for children. Child life specialists can help to normalize daily activities. Once the child is discharged from the hospital, encourage parents to allow the child to live life as

normal as possible. Social and medical staff have to help the parents to overcome their own fears, and to allow patients to return to pre-illness activities within the restrictions of the illness with no overindulging or overprotecting [54].


*2.2. Data and Data Management*

The daily maximum and minimum temperatures and the daily rainfall data of the study area for the period from 1985–2016 were obtained from the Agricultural Research Council (ARC) meteorological database and the South African Weather Service (SAWS). In this study, an agricultural year is defined from July to June of the following year. This allows the presentation of the growing period from October to April of the following year as a continuous record.

Meteorological data with the smallest number of missing data values (≤5%) were selected from stations within the municipality The UK method was used for the infilling of daily Tmax and Tmin values because of the technique's ability to accommodate the differences in altitude and its local effects. Missing rainfall data were estimated using the modified Inverse Distance Weighting method (IDWm), which allows for the influence of elevation on rainfall [41,42], missing rainfall, Tmin and Tmax values were less than 10% of the total data set, which satisfies the world meteorological organization (WMO) criteria for a robust climatic data analysis. Only stations with a complete data set having a duration of not less than 30 years were used for IDWm (Table 1).

Maize yield data (tons ha<sup>−</sup>1) for the Setsoto Municipality for the period between 1985 and 2016 were obtained from the South African Department of Agriculture, Forestry and Fisheries [43] for the four areas except for Ficksberg where data were only available for 1985–2005. Most of the statistical analyses were computed using quantum XL 2016 and JASP <IP_ADDRESS> statistical software. Collection and availability of temperature, rainfall and yield data are very limited in South Africa due to the lack of infrastructure and compliance, this is a common problem especially in SSA. It would have been ideal if these data could have been used together with other variables e.g., measurements of evaporation and radiation but again these data are not collected by the South African Weather Service nor by the farmer's unions.

The self-calibrating PDSI (Sc-PDSI) was calculated using monthly temperature and precipitation. A detailed description of the fairly complex calculation of the Palmer index consisting of five steps is published in several journals [21,44–46]. The Sc-PDSI accounts for all the constants contained in the PDSI and includes a methodology in which the constants are calculated dynamically based upon the characteristics present at each station location. The self-calibrating nature of Sc-PDSI is developed for each station and changes based upon the climate regime of the location. It has wet and dry scales. The index was calculated for three decades as well as for the entire data set from 1985–2016. According to Palmer [44], the range of the monthly index time series is between −4 and +4. Negative (positive) PDSI values indicate dry (wet) periods, while those near-zero presume a state that is close to the average rainfall. The Palmer hydrological drought index (PHDI), is used to assess

long-term moisture supply. The Sc-PDSI was calculated using a program developed by researchers in URL https://github.com/Sibada/scPDSI.


**7. Discussion**

These results raise the question of the extent to which the metacognitive skills, assessed by the Learning and Study Strategies Inventory, are influenced or associated with moving away from the home environment in order to engage in undergraduate study. In other words, does a significant change in the social context, like moving away from home to study, impact positively upon metacognitive development and, if so, why is this likely to happen?


**4. Conclusion**

Increasing concerns associated with overusing antibiotics in animals and humans make it urgent to find new alternatives for treating bacterial infections and diseases. BCAA pathways enzymes are promising antimicrobial alternatives being developed as potential drug targets absent in animals and humans. Comparative studies of KARI from different bacteria bestows the idea that this essential enzyme can be targeted for anti-bacterial drug design. Therefore, KARI is considered a good target, due to a non-homologous protein in comparison with human proteins, and its targeting will be safe for humans. In this review, we assess the presence of KARI in most human pathogens, especially the ESKAPE group, due to its high antibiotic-resistance causing severe infections.

Since the 3D structure for KARI from *N. gonorrhoeae* was nonreported yet, a model of this enzyme was produced using the Swiss model. Indeed, the *Ng* KARI was modeled in silico based on X-ray crystallography structure for *Sa* KARI, used as a template. It was evaluated that cofactors ligands (Mg2+ and NADPH) were conserved among human bacterial pathogens. Upon the binding of these cofactors, KARI adapts a different conformation allowing the substrate binding and catalysis, while the active site adapt to a closed state.

Competitive inhibitors, targeting the active site are promoting drugs for the growth inhibition of pathogens. However, the NADPH binding site and the active site are highly conserved among bacteria, including the gut microbiome. In fact, a growing number of studies have shown that antibiotics can result in microbial dysbiosis, due to their broad-spectrum activities, when subsets of commensal


**6. Novel therapeutic approaches**

For many years, the rise of brain metastases of lung cancer has been considered the final stage of the disease. Patients were treated with standard therapeutic options such as palliative care or whole brain radiotherapy (WBRT). However, since the discovery of new systemic and targeted therapies, additional effective treatments for lung cancer were introduced with the aim to enhance local control and survival [106].

### **6.1 Targeted systemic therapy**

The BBB is an obstacle to enter the brain for many agents and has limited the application of drugs used for systemic therapy [107]. The application of drugs targeting EGFR and ALK has heightened the interest in utilizing systemic agents to treat brain metastases [108–111].  Although the efficacy of EGFR-TKIs for NSCLCs with EGFR mutations has been proven, its effectiveness is not clear in patients with brain metastases since they were excluded from controlled clinical trials. In a prospective study, 41 patients with unselected NSCLC brain metastasis were treated with Gefitinib resulting in 10% intracranial partial responses (PR) with an average response period of 13.5 months [114]. However, most information on the efficacy of TKIs in patients with brain metastases was obtained from retrospective studies [110]. Firstly, it appeared that recorded concentrations of Afatinib, Erlotinib, and Gefitinib in cerebrospinal fluid (CSF) clearly exceeded those needed to inhibit the growth of cells with EGFR mutations *in vitro*. In patients with lung adenocarcinoma, about 70% intracranial tumor response was obtained with Gefitinib or Erlotinib as first-line treatment [115]. Other retrospective clinical studies revealed that patients with brain metastases from EGFR-mutant NSCLC have more favorable responses to WBRT or TKI therapy than patients with brain metastases from EGFR–wild-type NSCLC [116]. The progression periods were 11.7 months for patients with EGFR-mutant NSCLCs treated with Erlotinib and 5.8 months for patients with EGFR-wild-type NSCLCs, respectively [117]. The potent EGFR-TKI, AZD3759 showed significant penetration of the BBB in pre-clinical models for the treatment of EGFR-mutant NSCLC with brain metastasis [118]. Moreover, the third-generation EGFR inhibitors osimertinib and rociletinib targeting the T790M-EGFR resistance mutation in NSCLC appeared effective in treating patients with NSCLCs with these mutations [119, 120]. Unfortunately, a phase 3 trial conducted by RTOG using WBRT plus SRS with Temozolomide and Erlotinib in unselected patients with a maximum of three brain metastases was closed prematurely because of low accrual [121]. No significant benefit of adding Gefitinib to WBRT in phase 2 trials in patients with unselected NSCLC with brain metastasis was recorded [122].

*Non-Small Cell Lung Cancer Brain Metastasis: The Link between Molecular Mechanisms… DOI: http://dx.doi.org/10.5772/intechopen.106385*

> **Table 2.**

*Clinical trials of targeted therapy for the treatment.*

At present, there is not sufficient data to draw conclusions on TKI therapy plus CNS-directed radiation therapy for patients with NSCLCs with EGFR mutations.