Gender-affirming care in South Africa: A cross-sectional survey of transgender and gender-diverse people in the Eastern and Western Cape provinces, South Africa
DOI:
https://doi.org/10.7196/SAMJ.2026.v116i1.3523Keywords:
Transgender, Gender-affirming care, HIV, LGBTQI+, South Africa, Access, Health needsAbstract
Background. Transgender and gender-diverse (TGD) people face significant discrimination in the South African (SA) health system, limiting their access to HIV services and gender-affirming care, which supports an individual’s gender identity when it does not align with their sex assigned at birth. Despite the critical role of these services for TGD people, access to care remains understudied in SA.
Objectives. To describe TGD people and their access to and need for social, legal and medical transition, including psychosocial care, hormone therapy and surgery, as well as HIV services, in the Eastern Cape and Western Cape provinces, South Africa.
Methods. A cross-sectional quantitative survey design was utilised, with 150 TGD individuals recruited via convenience sampling in the Western and Eastern Cape provinces. Interviews were conducted using structured questionnaires, with data captured on REDCap. Descriptive analysis was conducted using Stata 18.
Results. Of the 150 respondents, 74.0% were people assigned male at birth (AMAB) and 26.0% were people assigned female at birth (AFAB). Reported gender identities showed that 68.5% of AMAB respondents identified as transgender women/female, 56.4% of AFAB respondents identified as transgender men/male and 34.0% of all respondents identified as gender diverse or non-binary. Demographics showed a vulnerable population, with 18.7% with housing insecurity and 66.0% unemployed. While social transition was common (98.7%), access to legal transition (4.0%) was very low, as was access to all forms of medical gender-affirming care, with 44.7% of TGD people accessing psychosocial care, 32.0% accessing hormone therapy and 2.7% surgery. Of the respondents who had not legally transitioned, 71.4% wanted to. Most respondents who had not accessed medical gender-affirming care services expressed a need for psychosocial care (77.1%) and hormone therapy (68.6%). Gender-affirming surgery was more variable, with 33.3% of AFAB respondents wanting bottom surgery compared with top surgery (63.9%), and 49.5% of AMAB respondents wanting bottom surgery compared with top surgery (55.9%). Almost all (99.3%) respondents had had an HIV test in their lifetime, with reported HIV prevalence differing between AMAB (34.2%) and AFAB (7.9%) respondents. PrEP uptake among HIV-negative AMAB respondents was 30.4%, and 5.7% among AFAB respondents, while 78.0% of TGD people living with HIV were on antiretroviral treatment.
Conclusion. Findings demonstrate a critical gap between needed and actual access to legal and medical gender-affirming care services. There is an urgent need for the provision of integrated and accessible gender-affirming care and HIV services as part of comprehensive care for TGD populations within inclusive health systems nationally.
References
1. Sutherland C, Roberts B, Gabriel N, Struwig J, Gordon S. Progressive prudes: A survey of attitudes towards homosexuality and gender non-conformity in South Africa. Pretoria: The Other Foundation, Human Sciences Research Council, 2016.
2. Müller A, Daskilewicz K. Are we doing alright? Realities of violence, mental health and access to healthcare related to sexual orientation and gender identity and expression in South Africa: Research report based on a community-led study in nine countries. Amsterdam: COC Netherlands, 2019.
3. Tshuma N, Mtapuri O, Ndagurwa P, et al. Populations size estimates for transgender persons in South Africa 2021. East London: BeyondZero, 2021.
4. Cloete A, Lynch I. Access to gender-affirming HIV, STI and TB services for transgender women in South Africa. Pretoria: Technical Advisory Committee for the Development of the National HIV, STIs and TB Policy Brief for Transgender Women in South Africa, 2021.
5. Metheny N, Mkhize SP, Scott D, Hatcher A. Violence victimisation and depressive symptoms among a sub-sample of sexual and gender minority adults in a population-based South African study. J Interpers Violence 2024;39(23-24):4699-4721. https://doi.org/10.1177/08862605241243348
6. StevensO,AndersonRL,SabinK,etal.HIVprevalenceintransgenderpopulationsandcisgendermen who have sex with men in sub-Saharan Africa 2010 - 2022: A meta-analysis. medRxiv 2023. https:// doi.org/10.1101/2023.11.09.23298289
7. Cloete A, Mabaso M, Savva H, et al. The HIV care continuum for sexually active transgender women in three metropolitan municipalities in South Africa: Findings from a biobehavioural survey. Lancet HIV 2023;10(6):e375-e384. https://doi.org/10.1016/S2352-3018(23)00059-0
8. Winter S, Diamond M, Green J, et al. Transgender people: Health at the margins of society. Lancet 2016;388(10042):390-400. https://doi.org/10.1016/s0140-6736(16)00683-8
9. Spencer S, Meer T, Müller A. ‘The care is the best you can give at the time’: Health care professionals’ experiences in providing gender affirming care in South Africa. PLoS ONE 2017;12(7):e0181132. https://doi.org/10.1371/journal.pone.0181132
10. Ritshidze. State of Healthcare for Key Populations. 3rd ed. Johannesburg: Ritshidze, 2024.
11. De Vries E, McLachlan C. Access to gender-affirming care in South Africa – a landscape in transition. In: Appenroth MN, Varela MdMC, eds. Trans Health International Perspectives on Care for Trans
Communities. Bielefeld: Transcript Publishing, 2022.
12. Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender
diverse people, version 8. Int J Transgend Health 2022;23(Suppl 1):S1-S259. https://doi.org/10.1080/
26895269.2022.2100644
13. Tomson A, McLachlan C, Wattrus C, et al. Southern African HIV Clinicians’ Society gender-affirming healthcare guideline for South Africa. South Afr J HIV Med 2021;22(1):1-27. https://doi.org/10.4102/ sajhivmed.v22i1.1299
14. Van der Merwe LA, Nikodem C, Ewing D. The socio-economic determinants of health for transgender women in South Africa: Findings from a mixed-methods study. Agenda 2020;34(2):41-55. https://doi. org/10.1080/10130950.2019.1706985
15. Müller A. Scrambling for access: Availability, accessibility, acceptability and quality of healthcare for lesbian, gay, bisexual and transgender people in South Africa. BMC Int Health Hum Rights 2017;17:16. https://doi.org/10.1186/s12914-017-0124-4
16. Poteat T, Malik M, van der Merwe LLA, et al. PrEP awareness and engagement among transgender women in South Africa: A cross-sectional, mixed methods study. Lancet HIV 2020;7(12):e825-e834. https://doi.org/10.1016/S2352-3018(20)30119-3
17. Jessani A, Berry-Moreau T, Parmar R, Athanasakos A, Prodger JL, Mujugira A. Healthcare access and barriers to utilisation among transgender and gender diverse people in Africa: A systematic review. BMC Glob Public Health 2024;2(1):44. https://doi.org/10.1186/s44263-024-00073-2
18. Scheim AI, Coleman T, Lachowsky N, Bauer GR. Health care access among transgender and nonbinary people in Canada, 2019: A cross-sectional survey. CMAJ Open 2021;9(4):E1213-E1222. https://doi. org/10.9778/cmajo.20210061
19. Carosella EA, Huerta L, Galea JT, et al. A cross-sectional analysis of self-reported needs and health service utilisation among transgender women in Lima, Peru. LGBT Health 2023;10(7):535-543. https://doi.org/10.1101/2022.02.01.22270281
20. Bretherton I, Thrower E, Zwickl S, et al. The health and well-being of transgender Australians: A national community survey. LGBT Health 2021;8(1):42-49. https://doi.org/10.1089/lgbt.2020.0178
21. Liu Y, Xin Y, Qi J, et al. The desire and status of gender-affirming hormone therapy and surgery in transgender men and women in China: A national population study. J Sex Med 2020;17(11):2291-2298. https://doi.org/10.1016/j.jsxm.2020.07.081
22. Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform 2019;95:103208. https://doi.org/10.1016/j. jbi.2019.103208
23. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) - a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42(2):377-381. https://doi.org/10.1016/j. jbi.2008.08.010
24. Shabalala SB, Campbell M. The high price of gender noncompliance: Exploring the economic marginality of trans women in South Africa. J Soc Incl 2025;13:8455. https://doi.org/10.17645/si.8455
25. Norris M, Borneskog C. The cisnormative blindspot explained: Healthcare experiences of trans men and non-binary persons and the accessibility to inclusive sexual and reproductive healthcare, an integrative review. Sex Reprod Healthcare 2022;32:100733. https://doi.org/10.1016/j.srhc.2022.100733
26. Moolman B. Rethinking ‘masculinities in transition’ in South Africa considering the ‘intersectionality’ of race, class, and sexuality with gender. Afr Identities 2013;11(1):93-105. https://doi.org/10.1080/14
725843.2013.775843
27. Schilt K. Just One of the Guys: Transgender Men and the Persistence of Gender Inequality. Chicago: University of Chicago Press, 2010.
28. Intersex Human Rights Australia. On the number of intersex people. Australia: IHRA, 2013. https://web. archive.org/web/20180717183724/https://ihra.org.au/16601/intersex-numbers/ (accessed 3 March 2025).
29. Puckett JA, Cleary P, Rossman K, Newcomb ME, Mustanski B. Barriers to gender-affirming care for transgender and gender nonconforming individuals. Sex Res Social Policy 2018;15(1):48-59. https:// doi.org/10.1007/s13178-017-0295-8
30. Almazan AN, Keuroghlian AS. Association between gender-affirming surgeries and mental health outcomes. JAMA Surg 2021;156(7):611-618. https://doi.org/10.1001/jamasurg.2021.0952
31. Doyle DM, Lewis TO, Barreto M. A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people. Nat Hum Behav 2023;7(8):1320-1331. https://doi.org/10.1038/s41562-023-01605-w
32. Turban JL, King D, Kobe J, Reisner SL, Keuroghlian AS. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS ONE 2022;17(1):e0261039. https://doi.org/10.1371/journal.pone.0261039
33. Campbell MM, Fresán A, Addinall RM, et al. Experiences of gender incongruence and the relationship between social exclusion, psychological distress, and dysfunction among South African transgender adults: A field-study for ICD-11. Ann Clin Psychiatry 2018;30(3):168-174. https://doi. org/10.1177/104012371803000301
34. Wilson D, Marais A, de Villiers A, Addinall R, Campbell MM. Transgender issues in South Africa, with particular reference to the Groote Schuur Hospital Transgender Unit. S Afr Med J 2014;104(6):448-449. https://doi.org/10.7196/samj.8392
35. Bateman C. Transgender patients sidelined by attitudes and labelling: Izindaba. S Afr Med J 2011;101(2):91-93. https://doi.org/10.7196/samj.4735
36. Koch JM, McLachlan Ct, Victor CJ, Westcott J, Yager C. The cost of being transgender: Where socio- economic status, global health care systems, and gender identity intersect. Psychol Sex 2020;11(1- 2):103-119. https://doi.org/10.1080/19419899.2019.1660705
37. Luvuno ZP, Ncama B, Mchunu G. Transgender population’s experiences with regard to accessing reproductive health care in Kwazulu-Natal, South Africa: A qualitative study. Afr J Prim Health Care Fam Med 2019;11(1):1-9. https://doi.org/10.4102/phcfm.v11i1.1933
38. Shabalala SB, Campbell MM. The complexities of trans women’s access to healthcare in South Africa: Moving health systems beyond the gender binary towards gender equity. Int J Equity Health 2023;22(1):231. https://doi.org/10.1186/s12939-023-02039-6
39. Constitution of the Republic of South Africa, 1996.
40. Statistics South Africa. Mid-year population estimates. Pretoria: Stats SA, 2021.
41. Stutterheim SE, van Dijk M, Wang H, Jonas KJ. The worldwide burden of HIV in transgender
individuals: An updated systematic review and meta-analysis. PloS ONE 2021;16(12):e0260063.
https://doi.org/10.1371/journal.pone.0260063
42. Sevelius JM, Deutsch MB, Grant R. The future of PrEP among transgender women: The critical role of gender affirmation in research and clinical practices. J Int AIDS Soc 2016;19:21105. https://doi. org/10.7448/ias.19.7.21105
43. Bothma R, O’Connor C, Nkusi J, et al. Differentiated HIV services for transgender people in four South African districts: Population characteristics and HIV care cascade. J Int AIDS Soc 2022;25(Suppl 5):e25987. https://doi.org/10.1002/jia2.25987
44. Müller A. Teaching lesbian, gay, bisexual and transgender health in a South African health sciences faculty: Addressing the gap. BMC Med Ed 2013;13:1-7. https://doi.org/10.1186/1472-6920-13-174
45. Lynch I. Justice, abundance, and possibility for all: Countering anti-gender movements in South
Africa. Cape Town: Afrikagrupperna, 2024.
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