Gender-affirming healthcare for transgender youth has sparked intense debate globally. In South Africa, we need to significantly improve accessibility throughout the country, ensure services are well-resourced, include trained healthcare providers skilled in gender-affirming care, and offer comprehensive care that integrates mental health and social services, write Jenna-Lee de Beer-Procter and Pierre Brouard, on behalf of fellow board members of the Professional Association for Transgender Health South Africa.
The discourse around transgender healthcare, particularly for young people, has become increasingly contentious. In a recent opinion piece published by Spotlight, Dr Janet Giddy, Dr Allan Donkin, and associate professor Reitze Rodseth criticised gender-affirming care for young people, raising several concerns. As board members of the Professional Association of Transgender Healthcare South Africa (PATHSA), we offer a different analysis, based on our extensive experience and expertise in transgender healthcare.
The recent UK Cass Review, led by Dr Hilary Cass, critically evaluated the Tavistock Gender Identity Development Service (GIDS) - the largest gender clinic in the world - which served trans and gender-diverse youth from 1989 until recently. Those who oppose gender-affirming care for trans and gender diverse youth have taken some of the findings, notably concerns expressed about puberty blockers for young people who wish to delay puberty while they are exploring their gender, as a sign that the report opposes such care. But in fact the review emphasised the need for individualised care, cautious, evidence-based medical interventions and decentralising transgender healthcare to improve accessibility across the UK.
In South Africa, similar steps are needed to both expand gender-affirming care for youth and prevent the collapse of the existing, limited, services. Currently, only one public facility, the Red Cross Children's Hospital's Division of Child and Adolescent Psychiatry (DCAP), assesses trans and gender-diverse youth, with their parents or carers. If appropriate, they are then referred to paediatric endocrinology at Groote Schuur Hospital for further evaluation and treatment.
Why are these services so limited?
Limited state resources are available for gender-affirming care and most who access it pay for it themselves and, in very rare cases, can access it through their medical aid. Only a small handful of paediatric endocrinologists, most of whom are based in Cape Town, work with trans and gender-diverse youth, leaving much of the country and rural areas without gender affirming care for youth. Waiting lists for surgeries are up to 25 years and in general, private treatment is expensive and out of reach for most.
As a mother of a trans child recently noted in a letter published on the PATHSA website:
"It takes months to see an endocrinologist and it must be done with the support of a psychiatrist. I have watched my child's despair as 'professionals' and adults decide his future. I have watched adults call him an abomination, refer to him as 'it' or 'confused'... My son hides in his bedroom, has panic attacks, won't shower because he has to undress, has swapped schools three times and yes, he attempted suicide at 13 and often cuts himself. Every day is a fight to keep my child alive."
This mother's anguish highlights the lack of services for, and the stigma and antipathy towards, gender-questioning youth. Her plea for healthcare professionals to "investigate the inequalities of healthcare in this country, talk to trans individuals about their healthcare needs and insert gender training into the medical school syllabus instead of meddling with a flawed report" underscores the critical need for comprehensive, accessible, and affirming care.
The Cass Review's cautious approach, as she critiques, delays necessary support and exacerbates the mental health challenges these young people face. A too cautious and delayed approach is a disservice to such young people.
While we support the Cass Review's broad call for more and better services, we place on record that some aspects have been weaponised, particularly the call for 'caution'. This has been interpreted as a rejection of puberty blockers and disapproval of social transitioning, where transgender people present in the world in ways which feel affirming. In fact, Dr Cass has distanced herself from earlier controversial statements questioning the benefits of hormone therapy for trans and gender-diverse youth. Despite inaccurate but widely-publicised views to the contrary, she clarified that the review did not conclude that puberty blockers are unsafe but recommended making them available at different ages and developmental stages alongside a broader range of gender-affirming healthcare based on individual needs.
Gender-affirming care for youth is far more comprehensive than merely prescribing puberty blockers and hormone therapy without due diligence. A nuanced, evidence-based approach is critical for supporting trans and gender-diverse youth. In gender-affirming healthcare, 'affirmation' means supporting youths' exploration with guidance and understanding, without pushing them towards a predetermined outcome. This holistic approach integrates psychotherapy, informed consent, social support, and medical interventions as needed. It is a multidisciplinary model which involves healthcare professionals, families, and individuals to support informed decision-making that respects self-determination and dignity.
Social transitioning
Social transitioning involves adopting a new name, pronouns, and clothing that align with a person's gender identity and is vital for supporting trans and gender-diverse youth. This process can significantly improve mental health by reducing gender dysphoria and promoting a sense of authenticity and acceptance. Despite its benefits, some critics argue against allowing children to socially transition. They claim this inevitably leads to medical interventions like puberty blockers, hormone therapy, and surgery - a 'slippery slope' fallacy. Social transitioning - and puberty blockers - are reversible and provide youth with an opportunity to explore their gender identity. Given the limited access to medical care in South Africa, most trans and gender-diverse youth can only socially transition, which is crucial for their well-being and exploration.
The Cass Review was critical of social transitioning, citing a study that assumed a correlation between social transitioning and increased suicidality. However, this interpretation overlooks the significant impact of bullying and discrimination: studies have shown that bullying, not social transitioning itself, leads to higher numbers of suicide attempts. When supported in socially transitioning, trans and gender-diverse youth exhibit improved mental health outcomes and reduction in gender dysphoria. For example, a study showed that using a chosen name significantly reduces suicidal behaviour and improves mental health among trans and gender diverse youth. Conversely, unsupportive environments worsen their mental health.
A significant critique of the Cass Review is of its ideological and methodological underpinnings. The fact that Dr Cass, a senior clinician with no prior involvement in gender-affirming care, was selected to lead the review is bewildering. As one senior UK psychiatrist observed: "I can think of no comparable medical review of a process where those with experience or expertise of that process were summarily dismissed." Suffice to say, it remains a contentious document. By contrast, the Southern African HIV Clinicians Society (SAHCS) Gender-Affirming Healthcare Guideline is a comprehensive, context-specific framework developed by 17 healthcare providers and researchers with input from an additional 27 contributors, all of whom are knowledgeable about trans issues and trans health.
One of the biggest challenges in South Africa remains the inadequate and inaccessible public health infrastructure, with limited resources and a shortage of specialised training for healthcare providers in gender-affirming care. This lack of education and training in gender-affirming care leads to ignorance and discrimination in healthcare settings, deterring trans and gender-diverse individuals from seeking necessary care. To improve healthcare for trans and gender-diverse youth in South Africa, we need to integrate comprehensive gender-affirming care education into health science curricula, ensuring that all healthcare professionals are equipped to provide respectful, informed, and effective care. State policies must recognise gender-affirming healthcare as an essential service, providing access at all levels of healthcare facilities and making it a standard part of medical training and practice.
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In conclusion, transgender healthcare for children and adolescents has sparked intense debate globally. As the global north grapples with deep divisions over transgender care, we strive for a different path in South Africa. If the Cass Review, and our own local situation, are to be taken seriously, we need to significantly improve accessibility throughout the country, ensure services are well-resourced, include trained healthcare providers skilled in gender-affirming care, and offer comprehensive care that integrates mental health and social services. This calls for a sober and thoughtful approach, not fear-mongering. We hope transgender healthcare in South Africa becomes less polarised and we remain focused on what is most important. Young trans people matter and deserve holistic care.
*De Beer-Procter and Brouard are both clinical psychologists. They write in their capacity as board members of PATHSA, a dedicated interdisciplinary health professional association committed to enhancing the health, well-being, and rights of transgender and gender-diverse individuals in South Africa. The fellow board members of PATHSA are: Rev Chris McLachlan, clinical psychologist; Dr Robin Dyers, public health specialist; Prof Elma de Vries, family physician; Dr Sakhile Msweli, clinical psychologist; Associate Professor Mershen Pillay, audiologist and speech therapist; Dr Arianne Spitaels, paediatric endocrinologist; Dr Allanah Wilson, psychiatrist; Luh Cele, clinical nurse practitioner.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
