gender reassignment surgery south africa

Breast, Endocrine and General Surgeon

Other pathology, gender-affirming top surgery.

As a practice that welcomes and respects the LBGTQI+ community, Dr Roodt and her team identified the need to offer a safe space for individuals seeking gender-affirming top surgery.

Dr Roodt has since performed several of these procedures with great success. Gender-affirming top surgery is a life-changing procedure and requires careful and respectful consultation between the patient, the surgeon, and all other specialists involved in the patient's gender-affirming journey (including an endocrinologist, psychiatrist, and psychologist). We will only proceed with surgery when all the necessary parties are in agreement that all the diagnostic criteria have been met and that the procedure will ultimately be in the best interest of the patient.

Dr Roodt is an active member of PATHSA (Professional Association for Transgender Health South Africa) and is thus committed to staying up to date with the latest developments in the field.

During a surgical consultation for gender-affirming top surgery (female to male chest), Dr Roodt will discuss the available procedures in detail and advise what options would suit the patient best. Approaches to gender-affirming top surgery include:

• Double incision nipple sparing pedicle approach Incisions are made under the breast in order to access and remove breast tissue without affecting the nipples.
• Double incision and nipple grafting approach Incisions are made through the nipples to access and remove breast tissue. During a nipple graft procedure for breast reduction, the nipple is surgically excised from the breast and replaced with a skin graft.
• Circumareolar approach The nipple and areola are repositioned when altering the shape of the breast.
• Simple mastectomy approach All of the breast tissue is removed during a mastectomy.

All of the above procedures may require simultaneous or delayed liposuction and fat grafting or contouring.

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Dr Trevino Ridgard

Transgender health.

• Gender is a complex internal sense of being male or female, or other.
• Transgender describes a person whose gender identity is different from the sex assigned at birth.
• Being transgender is a matter of diversity and not pathology.
• Gender affirming surgery is performed to make the body in line with the identified-with gender.
• WPATH and PATHSA guidelines followed for medical and surgical treatment.
• Within our multidisciplinary team, we offer top and bottom surgery.
• The details of the surgeries will be discussed extensively with Dr Ridgard.

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The Process of Gender Marker Change in South Africa

August 26, 2023 2 min read

The journey to aligning identity documents with one's affirmed gender can be challenging. This article will take you through the step-by-step process of changing your gender marker in South Africa, drawing from various experiences and insights.

Understanding the Legal Context 

South Africa has made significant progress in recognising the rights of transgender individuals. The Alteration of Sex Description and Sex Status Act (No. 49 of 2003) allows individuals who have undergone a sex change operation or medical treatment resulting in gender reassignment to apply for a change in their name and gender. This process requires validation through two medical reports.

South African Law and Gender Reassignment 

South African law recognises gender reassignment as a multifaceted process that extends beyond surgical options. This inclusive approach offers a lifeline to those seeking to align their identity documents with their affirmed gender, irrespective of surgical procedures.

Where and How Gender Is Marked 

In South Africa, the gender marker is included within the unique ID number.   When applying for a gender marker change, you will receive a new ID number that reflects your affirmed gender.

Documents Required 

To initiate the gender marker change process, you will need to gather the following documents:

• Form BI 526 (application for amendment)
• Form BI 9 (application for an identity book/card)
• Form BI 24 (notice of birth) filled out twice – once with your assigned gender and once with your identified gender.
• Two letters from medical professionals confirming gender reassignment.
• A copy of your birth certificate.
• Your existing ID book and a copy.
• Full-colour photos for ID (at least 2)
• A fee of R 210 (subject to change).

Journey of Personal Empowerment

Each person's journey is unique, but it is advisable to be well-prepared, patient, and persistent. Having a supportive person accompany you can provide additional assistance and comfort.

After submitting your application, staying informed about its progress is crucial. Regularly contacting the Department of Home Affairs (DHA) Hotline or using the mobile app for status updates is recommended. Max's experience demonstrates the importance of resilience and persistence when facing potential delays and challenges within the system.

Changing your gender marker may initially appear overwhelming, but it can be managed with adequate preparation, patience, and support. The pursuit of an ID book that accurately reflects one's identity is not only worthwhile but also achievable. 

Should you require assistance or guidance, reach out to our credible sexual health providers, who can support you on this journey.

Remember, you are not alone on this journey. Resources such as BeTrue2Me are ready to support and guide you through the process.

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A RARE PROCEDURE IN SA NEEDS A CONFIDENT SURGEON

Transgender & Sexual Reassignment surgeons are difficult to come by in South Africa. This is due to the complicated surgery and the conservative nature of South African surgeons in general.

This does not mean there is no demand for such surgery. Dr Serrurier performs a range of the surgeries required to complete male to female transformation, and he works in conjunction with other association sub-specialists to achieve your final result.

Dr Serrurier’s main area of specialisation lies in male to female transformation, with his expertise lying in Facial Feminisation Surgery and Breast Surgery. Charles works in conjunction with the transgender units in both Gauteng and Cape Town, and is committed to helping transgendered people become the person they were born to be.

For more information on Transgender and Sexual Reassignment Surgery,  contact Dr Serrurier’s rooms

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Changing your gender in South Africa

“I have some very vivid memories of when I was really young, say four or five years old, my grandmother would dress me in women’s clothing and say, ‘Look at my granddaughter’, but also in a playful way,’ says Sandile Ndelu, a transgender woman, who is a law student at UCT.

“But especially when you start reaching puberty, the expectations of which gender you should be and the strength of which gender you are assigned means that you have more people wanting you to conform to that,” she says.

Defining “transgender” is difficult because its definition is continuously evolving says Busisiwe Deyi, the legal research coordinator at Gender DynamiX, an organisation that focusses on the transgender community. “What I like to say is that [transgender people] are people whose gender is not in line with society’s assumptions about their sex,” says Deyi.

Accessing adequate and sensitised healthcare services is often difficult for transgender people due to the multiple levels of discrimination and the numerous obstacles they often face when visiting a healthcare facility.

“Two years ago, at the beginning of 2013, I was diagnosed with chronic kidney failure. That required immediate and urgent specialist medical care in order for me to actually survive. So it has been a long journey within the medical world and a deep engagement with medicine and doctors and nursing staff over the last two years,” says Ndelu.

“I had my kidney transplant at the end of last year and they [the doctors] always have to give an introduction [of the patient when they do ward rounds] and when one doctor was introducing me he kept referring in brackets to ‘transgender issues’. … Even referring to it as an issue was quite antagonistic towards me,” says Ndelu.

After her transplant, Ndelu had a few complications and another doctor who was deliberating on what to do said, “You know we [the doctors] should also consider that this is actually a man,” and laughed in front of her. “Of course in terms of my biology, it is an important consideration, certain patterns happen to certain bodies, but perhaps that could have been handled in a more sensitised way,” says Ndelu.

Ronald Addinall, who is a clinical social worker, sexologist and lecturer at UCT, is part of the team of medical professionals that run the Transgender Clinic at Groote Schuur Hospital, the only clinic of its level of expertise in the country, if not the whole of Africa. Addinall says that there have been changes in standards of care for transgender people and transgender people are also recognised by South African legislation. “But on the day to day reality and lived experience, that hasn’t necessarily translated for them,” he says.

If transgender individuals wishs to make not only a social transition, but also a hormonal and possibly a surgical transition to align their sex characteristics with their gender identity, they need to be diagnosed with “gender dysphoria”. This is when people’s gender identity does not match their sex assigned at birth and therefore causes them distress.

“Yes, hormones are an important element to some and surgery is an important element to some but often what happens is that one gets caught up in just that – getting hormones and surgery. There is a lot more in terms of a holistic healthcare point of view and services that the transgender community needs,” says Addinall.

Gender identity begins to form at a young age as Ndelu’s story shows. Addinall has even begun to work with children who identify as transgender, the youngest being a Grade 2 learner.

“Certain children will play, explore, experiment, and then you get the children who are persistently, consistently and insistently stating that they are not the gender that society is saying that they are and they become distressed, they become distraught, and that has been observed for a significant period of time. That would distinguish the transgender child from the mother who phones me saying, ‘My little boy was wearing my high heels walking down the passage, does this mean he is trans?’ ” explains Addinall.

Once young people turn 18 they can begin the process of transitioning, but this is not always easy. The only public facility that offers a consistent and reliable programme is the Groote Schuur unit. The Steve Biko Academic Hospital in Pretoria also offers gender alignment surgery but transgender advocates say that the unit is not as good as Groote Schuur’s.

Accessing hormones is relatively simple but accessing surgical treatment will mean a wait of between 21 to 27 years at Groote Schuur, if the current rate of four surgeries a year continues. This number is based on a formula that the hospital uses to allocate theatre time.

Currently only one medical aid, Bankmed, has paid for any surgeries, meaning that even if patients have medical aid they will probably need to pay out of their own pocket, or prepare themselves for the long wait at Groote Schuur. Deyi says that the private route is prohibitively expensive and most surgeons don’t have the expertise, so many patients go overseas for the surgery, where it is cheaper and more surgeons are skilled in practices such as colon grafting and creating vaginal canals.

Many transgender people also struggle to find work, especially when their identity documents and the gender that they present do not match up. Altering one’s sex description on an ID is provided for by the 2003 Alteration of Sex Description Act. The Act says that “any person whose sexual characteristics have been altered by surgical or medical treatment or by evolvement through natural development resulting in gender reassignment, or any person who is intersexed” may apply for sex description to be altered on the birth register.

But this is often a difficult process. Deyi says that even though the Act doesn’t require surgical intervention, meaning that hormonal treatment is sufficient, many clerks at Home Affairs offices will turn people away who have not had surgery due to the clerks’ incorrect interpretation of the Act.

Deyi is aware of a person who has been waiting for seven years for an ID alteration. One of the problems with this is that the person cannot leave the country to receive gender alignment surgery because of of the difference between their identity document and their gender presentation.

“Government can’t provide the health-care, but when you do try and access it, they prevent you,” says Deyi.

“In a perfect world I would like the ID to have either a third gender like X or just blank, I don’t see why we need to have that as an identifier,” she says.

Ndelu, who has yet to change her ID, says when she was trying to get a cellphone contract the store assistant put her ID number and her gender representation into the system but the programme refused to accept the incongruence.

“If my ID document and if my name is gendered in a certain way, I want to … disrupt space, to make things not normal, to look at the shop attendant while I am trying to get a contract and say, ‘I am a transwoman’. And look him in the eye for that and disrupt the everyday erasure and invisibility of transbodies.”

Places where transgender people are made to feel welcome and where their concerns are vocalised are often scarce. One such space that provides an advocacy, educational and community role is the TransCollective at UCT, of which Ndelu is a founding member. Ndelu says that UCT purports to be a certain type of institution and the TransCollective is here to “call them out” when they believe that the university is not living up to their standards. “We have passed the state of negotiation and debate, we actually are saying that this is what people need, so do it.”

Ndelu believes change in South African society is not happening as fast as it should. She says that in many ways UCT is just a reproduction of the rest of the country. “Decisions about changing attitudes, decisions about active measures to start changing the fabric of society are taken by people who aren’t even affected by these issues,” she says. “When people like me raise their voices, when people like me protest, when people like me ask the institutions to see us, and make provisions for us – the institutions don’t listen. How can we think that they are serious about creating change within this institution and within the broader South Africa when they can’t even listen?”

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It is hard changing your gender

Dear Editor

I wish it was possible to explain in straightforward words what impact this gender thing has on a person with this problem.

It sometimes seems that most people think it is a decision that a transgender makes. In other words, they think we just try to be funny or something like that.

Let me please tell you about the emotional aspect. No other person can ever know how you feel, and how damaging it is to us. Not even if you meet a partner that says she or he accepts you for who you are.

You don't accept yourself. How will others do that?

I sometimes wish I was never born, or born as it should have been. The bitterness eats me up. This was not my decision to be born like this. I didn't ask for this, and believe me, none of the others did.

I went three times in at Steve Biko for a penis construction, and every time it was moved because of an emergency. The first time I was physically lying on the theatre bed, IV connected,the works. Then the doctor came in to tell me the bad news. No surgery for you old friend. That was horrifyieng. Then months later the same thing, and then again. In the end I asked them to just remove the "balloon" in my arm, for it has become clear to me it will never happen for me.

So, in short, I have the body of half a human. That makes me in this life not a person, just an empty shell.

Sincerely barend steyn 20 Sep 2016

Transgender in the township

Growing up, I always knew that I was different from other boys. It was hard growing up with no one understanding me and seeing me as a delinquent. I was always intelligent, but my life was at a standstill. I did not get much support. I was abused because I am transgender. No matter what happened, I did not give up. I started cross-dressing at 19. It was amazing seeing how beautiful I had become. A lot of people could not tell I was a man. But there are those who always point fingers. I still have a long way to go. First, finishing my degree next year. And I still feel incomplete. I want to start the hormone treatment, but I do not know how I will, because I am currently unemployed and studying. It's been hard. I hear alot about Groote Schuur Hospital but I hardly hear about hospitals in Pietermaritzburg that support the transgender community.

Sincerely Anonymous 15 Nov 2016

Frustrated mother of a transgender child

I am the mother of a FTM transgender. My son really wants the hormones and surgeries. Why are the medical aids not assisting their members? This is not cosmetical. This is his life we are talking about. A boy who needs his body to show what he is. Medical aids are expensive... and for someone to be trapped in the wrong body and to have gone through self-harm and suicidal thoughts but the surgery is cosmetic? I beg to differ. It's life or death. If not physical death... but the death of my son's spirit if I cannot find a way. Must I become unemployed for my son to get help? I'm a frustrated parent who wants a happy healthy son.

Sincerely A mother to a wonderful boy trapped in a girls body 17 May 2017

Coming out as transgender

I am Ruan, a boy of 18 years old but inside I am a girl named Sasha. Growing up I always played with girl toys and never found interest in boy stuff. I would dress in my mother's and sister's clothing and say I am a beautiful girl. Now I realize I am transgender and I am a girl that needs to come out and go live her life. I am currently still a boy but want to change to my real self so badly BUT I am scared of what others will say even though it's not them who should be happy. I must be happy which I am not so this is my story.

Sincerely Ruan Bekker aka Sasha 9 May 2018

No support for transgender learners

I'm a boy named Fortune but as I was growing up as a child. I never had any interest in boys activities I always played with dolls etc. When I was 4 or 3 years old, my mother would put me in my sister's dress because I loved it until I found out that I'm transgender male-to-female.

I don't know where to start with my transition, taking hormones or undergoing the surgery. I'm a girl inside. I have changed my name to Sasha but I just can't get help. It's been hard for me at school because I once wore a skirt but I was shamed by a few teachers, even my life orientation teacher.

Sincerely Sasha 16 Jan 2019

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Trans in South Africa: A Personal Account on Medical Transition

If you’re a trans person or an ally closely associated with a trans person, you likely know that transition is both an emotionally and financially taxing process.

That said, the state or country in which you live can have a huge impact on how easy or challenging that process can be. Depending on where you are transitioning, the support offered by your country’s healthcare system can drastically affect the viability of medical transition. I wanted to share my experiences (so far) as a 21-year-old trans guy in transition in South Africa, and how my location has impacted my journey in obtaining gender-affirming care.

South Africa’s healthcare system for trans folks

As a developing country, South Africa’s healthcare system is drastically underfunded for the overwhelming number of people who rely on it.

Because of the large number of people who need the public system to meet their basic healthcare needs, trans health is a non-event. By this, I mean: should you have to use this system for hormone replacement therapy (HRT), the waiting list is about 5 years long. Obtaining support for gender-affirming surgery is even more challenging. Should you wish to have top surgery through the public system, for example, the wait is 25 years. This is largely because any transition-related surgery is deemed to be cosmetic, and thus only one procedure is performed annually.

I am in the very fortunate position to be able to afford private care with the help of my parents. At first, this made me think that my medical transition would be a fairly swift process. I’ve now learned this is not the case.

Finding competent providers

After having phoned what seemed like 50 endocrinologists, I finally found Dr. Debbie Gordon. In my country, there are very few health care providers who have experience with transgender patients. She was the first person out of so many doctors that I contacted who agreed to treat me and had treated at least one trans person prior. Once we made contact, my first appointment with her required a three-month waiting period, and each appointment came with an out-of-pocket expense of R1500 (about $100 USD). Not only was this a long time to wait for care, but for folks with limited resources, getting and keeping a hormone prescription is simply out of reach.

After I had been on testosterone for about 10 months, Dr. Gordon told me I would be eligible for top surgery. I was extremely excited and thought that because she had previously helped a trans patient, she might be able to help connect me with an experienced surgeon. Once again, I was wrong.

She referred me to a very well-known South African breast surgeon, but during my consultation with him he confessed that he had never worked with trans person before. At one point in the consultation, he actually asked me if I knew how the top surgery procedure should be done. As you can imagine, this was quite unnerving.

Because I felt so desperate to have surgery this year, I agreed to a surgery date with him, but later voiced my concerns to my mother. Thankfully, my mother heard my doubts and took matters into her own hands. She contacted the Plastics and Aesthetics Board on my behalf and learned that there are only 3 surgeons qualified to work on trans people in my country. Luckily in my case, one of these surgeons operates about 20 minutes away from my house.

This time, I had done my homework: I watched multiple video consultations with Dr. Charles Garramone (a leading top surgeon in the United States) so I understood the basics of the procedure. When I met with Dr. LCJ Surrerier, he thankfully understood the care I was looking for. Without any prompting, Dr. Serrurier explained his surgical approach, which is similar to that of Dr. Garramone. However, he did offer a disconcerting reminder during our meeting, one that I had not considered in my research: due to the high rates on violence on LGBTQ+ people in South Africa, he only performs the peri-areolar procedure in an effort to keep post-op patients safe.

Affording care

Meeting done and dusted, it was time to get down to the nitty gritty and talk money. Dr. Surrerier informed my mother and me that no South African medical aid or insurance will cover any transgender-related surgeries. Despite the fact that Gender Dysphoria is in the DSM-V, my country’s medical policies continue to class these surgeries as cosmetic. This is a huge barrier for so many trans South Africans. In my case, the total cost of surgery was R65,000 (about $4,600 USD) with an additional R1500 (about $100 USD) in order to import a special post-operative vest from Underworks in the United States. Thankfully, all post-op care and check-ups were included in the above costs. For others, expenses like travel and lodging accommodations may be an important consideration, too.

Post-op and looking forward

Writing this in early 2019, I am two weeks post-op and extremely grateful for my parents who have funded my procedure. I am very aware that this is a privilege and that many, many people will not be so lucky. Following further discussions with Dr. Serrurrier, I am even more sure that the costs surrounding top surgery are the main reason why Dr. Serrurrier has performed top surgery less than 10 times (especially when you keep in mind that he is the expert in South Africa.)

Personally, I do not see bottom surgery in my near future, but during my efforts to find a top surgeon I did find out some bottom surgery information which may be helpful to others. At this time, there is only one qualified bottom surgeon in South Africa named Dr. Kevin Adams, who operates out of a private hospital near Cape Town. As most trans masculine people know, bottom surgery is a three- or four-stage process. Stage 1 alone in South Africa with Dr. Adams costs R300,000 (about $20,000 USD).

Transition is an ongoing process and it looks different for each of us. Along the way, I’ve learned firsthand how challenges can vary depending on your location, but in South Africa, the greatest one is definitely the financial burden and lack of assistance in obtaining care.

Written by Point of Pride

Point of Pride provides financial aid and direct support to trans folks in need of health and wellness care.

About the author

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Policy guidance: improving access to gender-affirming healthcare for transgender women.

Transgender women in South Africa have actively participated in HSRC studies to explain structural, social and cultural factors contributing to their disproportionate health and social burdens. Some of this and other research has been synthesised into a policy brief to inform better healthcare and other services for this marginalised group. The findings and recommendations of this policy brief by Dr Allanise Cloete are summarised by Antoinette Oosthuizen.

Transgender women face healthcare and socioeconomic challenges due to stigma, discrimination, exclusion, gender-based violence and restricted access to services and resources. Using a participatory research approach HSRC researchers have worked with this community in studies aimed at understanding and improving their lives. Focusing on healthcare, some of this work has informed a briefing document that aims to guide policies towards improving services and support for transgender women.

Gender nonconformity and the need for better policy

Transgender women are individuals who were assigned male sex at birth but socially identify as women. The issue is complex, as some individuals also identify as gender-fluid or prefer not to conform to traditional gender labels. They may also be straight, gay or bisexual or find conventional sexuality labels inapplicable.

The policy brief on improving transgender women’s access to gender-affirming healthcare dedicates a section to describing current policy and highlighting gaps. For example, the South African Constitution prohibits discrimination based on sexual orientation and gender, and the Alteration of Sex Description and Sex Status Act, 2003 (Act No. 49 of 2003) makes provision for transgender people to align their legal status with their lived gender identity. However, this Act is ‘inherently medicalised’ and excludes the majority of trans and gender-diverse persons from accessing legal gender recognition, since it requires a medical diagnosis and intervention.

But many working class, peri-urban or rural transgender persons can’t afford the medical and surgical care needed for transition, which is limited to private and academic hospitals located in major city centres. The Act also only recognises the selection of one of two genders, and not fluid or non-conforming identities.

Photo: Helder, Pexels

HIV and TB prevalence

In 2015, the population size for transgender women was estimated at 72,156 after an HSRC mapping study commissioned by the Global Fund through the South African National AIDS Council.

In 2018 and 2019, the HSRC conducted the Botshelo Ba Trans Study , the first ever bio-behavioural survey among transgender women in South Africa, with 888 participants from the metropolitan areas of Cape Town, Johannesburg and Buffalo City.

The findings showed that HIV disproportionately affected transgender women, with an HIV prevalence among participants of 63.3% in Johannesburg, 46.1% in Buffalo City and 45.6% in Cape Town. This reflected estimates among transgender women in Lesotho (50%), Mumbai, India (63%) and in a study conducted by the US Centers for Disease Control and Prevention among ‘black’ African American transgender women (51%).

Despite tuberculosis (TB) being one of the most serious HIV-related health conditions, and despite transgender women already being prioritised as a key population for HIV, they have not been included as a key population for TB interventions in South Africa’s National Strategic Plan for HIV, TB and STIs (2017–2022) . No formal prevalence studies of TB among transgender women in South Africa exist, nor do gender-disaggregated data from routine surveillance statistics. In South Africa, organisations representing transgender women have reported a high burden of TB among their members, driven by poverty, poor living conditions, high HIV prevalence and stigma . Poverty, unemployment and homelessness are also key predictors of HIV risk and low retention in HIV care.

Unemployment

Unemployment rates among transgender women in the Botshelo Ba Trans Study ranged from 30% to 60%, with the majority having no income. Some end up being homeless or living in extreme poverty. Their employment pathways are disrupted early on , often through education exclusion due to school-based victimisation and social rejection. Many don’t have family support and experience workplace discrimination if they do find employment. In the South African context, intersections between race, class and gender further compound the socioeconomic vulnerability experienced by ‘black’ and ‘coloured’ transgender women.

Expressing their identity resulted in rejection by family, schools, churches, community structures and previous friendship circles. This rejection of identity was seen as deeply entrenched and highly sensitive. The researchers emphasised that the impact of stigma and social exclusion should not be seen as a single event or a series of individual events, but as a continuous process, which renders them vulnerable to poverty and ill health.

Recommendations in the policy brief

The researchers and transgender participants made several recommendations in the policy brief.

Addressing legal changes included advocating for policy reform to ensure equitable access to gender-affirming care, including hormone therapy. They recommend that gender recognition law be demedicalised and allow for broader inclusion beyond the gender binary.

Baran Lotfollahi ,  Unsplash

Furthermore, the Prevention and Combating of Hate Crimes and Hate Speech Bill needs to be passed into law to combat hate speech and transphobically motivated hate crimes. The National Strategic Plan on Gender-based Violence and Femicide should also be refined and implemented to combat trans-misogyny, transphobia, and gender-based violence and femicide directed at this community.

The policy brief recommends various changes to the health system, including decentralisation of hormone therapy initiation and continuity of care from tertiary healthcare to the primary healthcare level. For example, the requirement for an endocrinologist to monitor gender-affirming hormonal care management is a major barrier to access for transgender persons, given that so few such professionals exist in South Africa. By decentralising gender-affirming hormonal care to primary healthcare providers, these services can be brought closer to where people live, including in rural areas.

This requires that training in the provision of gender-affirming healthcare to transgender women should form part of the primary healthcare training curriculum. Peer educators can help recruit and retain transgender women in care, and the National Department of Health should invest in established trans-led civil society organisations that provide transgender-friendly psychosocial services.

The brief recommends that hormone therapy be included in the essential medicines list and distributed via the government’s Central Chronic Medicines Dispensing and Distribution programme, which provides access to medications via community-based pick-up points instead of health facilities. Another suggestion was to use smartphone platforms to engage and retain transgender women in care.

The researchers also highlight sexual and reproductive healthcare as an area with a narrow focus on the provision of maternal and other reproductive healthcare services to heterosexual cisgender women. They recommend that holistic, tailor-made packages of care be developed for transgender persons to address issues such as fertility.

The researchers also advocate for medical aid scheme policy amendments to remove the exclusion of trans-affirming care from prescribed minimum benefits, in line with equity and social justice goals underpinning the reforms towards a National Health Insurance health system.

The transgender women and their organisations involved in the writing of this policy document have requested further involvement in the design, implementation and monitoring of the new systems.

Ongoing research

HSRC researchers are currently busy with a study analysing transgender and gender-diverse students’ experiences, needs, challenges, policies and best practices at nine South African universities. According to Dr Allanise Cloete, a chief research specialist in the HSRC’s Human and Social Capabilities research division, the findings of this work may help us to understand institutional factors that are likely to shape the experiences of trans and gender-diverse students in higher education institutions in different parts of South Africa.

Researchers are also planning a study to look at safety and social justice for transgender and gender-diverse persons in Southern Africa: “The main aim of this research will be to explore how violence affects their lives. We will look at structural violence such as policies and laws that are inherently discriminatory towards trans and gender-diverse persons, systemic violence, which includes social stigma, and personal violence, including physical violence and hate-motivated crimes against trans and gender-diverse persons.”

Dr Allanise Cloete, a chief research specialist in the HSRC’s Human and Social Capabilities research division

[email protected]

The policy brief was summarised and edited by Antoinette Oosthuizen, a science writer in the HSRC’s Impact Centre

[email protected]

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How Much Does Transgender Surgery Cost In South Africa

Sex reassignment surgery (SRS), also known as gender reassignment surgery (GRS) and several other names, is a surgical procedure (or procedures) by which a transgender person’s physical appearance and function of their existing sexual characteristics are altered to resemble those socially associated with their identified gender.

It is part of a treatment for gender dysphoria in transgender people.

The term is also sometimes used to describe surgical intervention for intersex people.

As most trans-masculine people know, bottom surgery is a three- or four-stage process. Stage 1 alone in South Africa with Dr. Adams costs R300,000.

Transition is an ongoing process and it looks different for each of us.

How much does top surgery cost in South Africa?

If you are FTM and looking for costs of chest surgery, that vary between R15 000.00 and R26 000.00 (average of a few people).

Hyst etc can vary in more or less the same price range.

Can you be transgender without surgery?

Many transgender people transition without using hormones or surgery.

Nonmedical options include: Living as your gender identity.

This includes changing your clothing, name, speech, or other things.

How does female to male transgender surgery work?

During this procedure, the patient first undergoes vaginoplasty and a complete hysterectomy including removal of the ovaries.

The existing outer genitalia is then used to create a penis that retains sensation and some function, along with a male urethra.

How successful is transgender surgery?

Depending on the procedure, 94% to 100% of people report being satisfied with their surgery results.

In general, people who work with a mental health provider before surgery tend to experience more satisfaction with their treatment results.

Can you reverse transgender surgery?

Sex reassignment surgery (SRS) has proved an effective intervention for patients with a gender identity disorder.

However, misdiagnosed patients sometimes regret their decision and request reversal surgery.

Do you have periods with HRT?

Yes . If you are taking monthly cyclical HRT you should roughly have a bleed each month.

If you are taking three monthly cyclical HRT, you should have a bleed every 3 months.

Does HRT make you look younger?

One of the benefits of hormone replacement therapy is that it can make you look younger.

Hormone replacement therapy, or more specifically estrogen, can help reduce the appearance of fine lines and wrinkles on the skin.

It can also promote hair growth, which can contribute to a more youthful appearance.

Wednesday, 10 July

15 Sep 2021

In-depth: The incredibly long wait for gender-affirming surgery for those who can’t pay

In South Africa, gender-affirming care is mostly only available in the big urban centres of provinces such as Gauteng, the Western Cape, KwaZulu-Natal, and the Eastern Cape.

Transgender people from rural areas or provinces where gender-affirming care is not available must travel long distances to the major cities to access these services.

“There are huge waiting lists and a scarcity of surgical expertise in South Africa. In the private sector, it costs hundreds of thousands of Rands while in the public sector, waiting periods are often quoted as being north of two and a half decades,” says Dr Anastacia Tomson, an author and activist focusing on queer and transgender rights.

Dr Kevin Adams, a consultant plastic surgeon who also works at Groote Schuur Hospital, confirms that the waiting list for gender-affirming surgery is inordinately long.

“The Covid-19 pandemic has meant that we have been unable to do these operations for 18 months,” says Adams. The waiting list for surgery is over 300 patients long and as one operation can take a day, this means that there is a very long waiting list.

"We do not decide which surgery are permitted, but the vast majority of patients want at least one operation. Since the service was started in 2009, the number of patients entering the service has increased exponentially,” he says.

In 2009, Adams says they were seeing four to five new patients every three months and at the beginning of 2020, the number had doubled.

“There has been no increase in the amount of operating time as the service has increased, and therefore the waiting list continues to grow. There is only one surgeon performing these operations at Groote Schuur,” he says.

Dr Simon Pickstone-Taylor is a Child and Adolescent Psychiatrist, and General Adult Psychiatrist. Pickstone-Taylor, who set up the Gender Identity Development Services (GIDS) within the Division of Child and Adolescent Psychiatry at Red Cross Hospital, says the waiting list is generally 25 years for youth and or adults.

“They (trans teens) are on the same list (with adults). Their starting date is when they first consult the Gender Identity Development Service. None of the youth has had top surgery on the state list to date. All those who have had top (or bottom surgery) have had it with parental finance and a very few with medical insurance paying. T

"he state only allows very limited funding for these surgeries, thus the long waiting list,” says Pickstone-Taylor. (Top surgery refers to surgery that changes the appearance of the chest, while bottom surgery refers to surgery that alters the genital area.

Trans kids at a disadvantage

The mother of a 17-year-old transgender adolescent, who prefers not to be identified, says unless you live in Cape Town and are lucky enough to be accepted through the Red Cross War Memorial Hospital or Groote Schuur Hospital programme the only way to receive healthcare support is in the private sector.

“It is very expensive. Discovery Health has a pilot programme to support and affirm trans members but it remains limited and the barriers to entry are financially excessive with a lifetime limit of R200 000 in partial payment benefits,” she says.

She says there is no surgery for trans children in the public health system other than a few cases through Red Cross Children’s Hospital and before that is done, parental consent is needed.

Other surgeries tend to only be available to trans people from the age of 18.

“Young trans people do not always want or need surgery. The other social and medical interventions like hormone therapy are the first steps. What is often the case is that trans boys may need top surgery as soon as possible and this is the sort of initial surgery that a trans young person may need to remain alive.

"In South Africa, the only way for a minor to access top surgery will be through parental consent and in most cases at enormous cost in the private sector and then only with a surgeon who is happy to do this surgery,” she says.

She says less invasive surgeries such as top surgery are available through the private sector at an enormous cost. “Our son had top surgery at 14. All other surgeries remain an option for trans people and this is a very personal choice. We are researching surgeons in Serbia, Thailand, and the USA,” she says.

According to Pickstone-Taylor, the waiting list for surgery in the public health sector is so long that none of those under 18 would be still under 18 when offered surgery.

“Parents have to pay privately for top surgery and we work as a multi-disciplinary team to support those that want surgery before 18 and have parents who [can] pay for it. We have to ensure that the young person is psychologically prepared and supported enough to cope with surgery.

"Very few transgender male youth are lucky enough to have parents who can afford to pay for top surgery before 18 years old,” says Pickstone-Taylor, adding that their parents are always needed at this assessment.

The mother quoted earlier suggests that many transgender kids and teens are suffering from mental health problems in part because of the limited access to gender-affirming treatment. “This is why over 50% of transgender children try to kill themselves.

The argument we made to Discovery Health to include adolescents in their Pilot programme (it was previously only for adults) included all the clinical reasons but on a straight financial basis it is cheaper to affirm our kids than to have them in psych clinics trying to kill themselves every year,” she says.

Discovery Health had not responded by the time of publication.

But according to the Acting General Manager of Stakeholder Relations at the Council for Medical Schemes (CMS), Mmatsie Mpshane, the council has engaged the Department of Surgery at the University of Cape Town to discuss funding of gender reassignment surgery by medical schemes.

“It was established that the surgery was not [a] predominant and prevailing level of care across the South African public health sector. This implies that it is not Prescribed Minimum Benefit (PMB) level of care and funding thereof is subject to scheme rules, varying across schemes and dependent on [a] member’s benefit option or plan type.

"The CMS does encourage schemes to consider funding of these procedures as part of its yearly rule registration and approval process,” Mpshane tells Spotlight, explaining the PMB review process is ongoing with stakeholders’ inputs and participation. She said submissions relating to improved access to healthcare for all South Africans, especially vulnerable groups, are welcome.

Why access to gender-affirming care matters

Pickstone-Taylor says that 50% of transgender children will try to kill themselves if they do not get appropriate support.

“Children need social transitions,” he says, “for example when they request to change one or more of the following: name and pronouns, toilet change, and sports and school uniform change. If supported and allowed to socially transition, co-existing psycho-pathology invariably disappears the same day for pre-adolescent children.

"Equally, for adolescent children, suicidality and co-existing psycho-pathology disappear rapidly when allowed to take hormones to either stop puberty or cross-sex hormones. They are lifesaving in many cases,” says Pickstone-Taylor.

Chris McLachlan, the chairperson of PATHSA (an interdisciplinary health professional organisation), says studies indicate that Trans and Gender Diverse (TGD) people that are not able to access gender-affirming care have a 42 to 45% suicidality rate , meaning they would have attempted suicide in their lifetime.

“This [number] comes significantly down once the TGD person was able to access gender-affirming healthcare. Often, TGD people experience minority stress .

Minority stress, he explains, is the stress that TGD people experience as they navigate a hetero-cisnormative world where they are marginalised, discriminated against, not accepted and affirmed, and even become victims of violence. We find that more TGD people suffer from anxiety and depression and this is often due to, or compounded by, the minority stress,” says McLachlan.

Gender dysphoria

Clinical psychologist, Jordan du Toit says to be trans is associated with a condition called gender dysphoria, and while this is not a mental illness, it relates to the distress a trans person feels when their body does not match their internal sense of their gender.

“Gender dysphoria is associated with increased anxiety around your body and how it is seen by others, distress that your body does not match outwardly how you feel internally, and decreased pleasure in your body for things like sex, exercise, and daily living,” says du Toit.

This, du Toit says is a very traumatic experience to go through, and similar to other invalidating experiences (like sexism, racism, ableism) transphobia can be a real threat to trans individuals’ sense of acceptance and physical safety in the world.

“This can mean trans individuals mask or hide who they are to exist safely in the world or suffer from higher than average anxiety levels related to harassment and transphobia from others.

"The trans community is more at risk of suffering from post-traumatic stress disorder as a result of transphobic attacks, and this has a knock-on effect as it can lead to depression. The LGBTIQAP+ community at large is more at risk for suicide because of abuse and related depression,” says du Toit.

She adds that to be trans can be expensive.

“For a cisgender person (someone whose gender identity matches their biological assigned sex at birth), their bodies produce the hormones needed to maintain a congruent outward appearance.

"For someone who is trans, they need additional support for things like hormone therapy and affirmative surgery to help diminish gender dysphoria,” says du Toit, adding that the struggle to find affordable medical care can increase gender dysphoria and heightens the risk for mental illnesses such as depression.

McLachlan says the mental health risk is higher predominantly due to living in a world that is often unaccepting and also having to navigate a world that is not structured for diversity in gender and diverse gender expression.

“The TGD person needs to navigate an unwelcoming world, needs to navigate so many barriers and gatekeeping in various healthcare structures in order to live freely as the person they are and has to deal with rejection, hate, and marginalisation,” says McLachlan.

Trans persons at higher risk for HIV

A meta-analysis published in The Lancet suggests that internationally transgender women are as much as 49 times more likely to contract HIV than adults of reproductive age in general. Since the rate of HIV in adults of reproductive age in South Africa is extremely high, the ratio will be lower here - although that obviously doesn’t preclude the likelihood that South Africa may have some of the world’s highest rates of HIV infection in transgender people.

According to Nelson Dlamini, spokesperson for the South African National AIDS Council (Sanac), HIV risk in transgender women is embedded in multiple co-occurring public health problems.

Speaking to Spotlight, Dlamini says there are high rates of unprotected anal sex among transgender women, which carries a higher risk of HIV transmission than vaginal sex.

“Several factors contribute to this stigma and discrimination, leading to low self-esteem and disempowerment [which] can make it harder for transgender people to insist on condom use. In many settings, condom use is often controlled by the insertive sexual partner, so many transgender women who have sex with men can feel unable to instigate condom use,” he says.

Dlamini further states that “gender-changing hormones, which some transgender women use, can lead to erectile dysfunction, increasing the likelihood of taking the receptive role during sex,” he says, adding that there are other social factors that make transgender people more likely to engage in high-risk sex.

Dlamini says studies have shown that some transgender people who want to affirm their gender identity through sex, or who fear rejection from sexual partners can be more likely to agree to unprotected sex.

“Evidence-based multilevel interventions that address the structural, biomedical, and behavioural risks for HIV among transgender populations, including transgender men, are needed to address disparities in HIV prevalence.

"Tailoring HIV testing activities to overcome the unique barriers faced by transgender women and men have increased rates of testing among these populations,” he says.

Towards solutions: Improving health systems

According to Gender Dynamix’s Adriana Beukes, there is a need for resources and sensitising of healthcare providers and administrators.

“There is a dire need for more trained and specialised doctors who can perform vaginoplasty , clitoroplasty and labiaplasty for women, and hysterectomy and oophorectomy , as well as metoidioplasty or phalloplasty , scrotoplasty /testicular implants for men,” says Beukes.

Beukes says part of the challenge is a lack of scientifically-based policy and protocols in the public health system which means that gender-affirming care is frequently seen as elective and non-essential, and is often only available at tertiary facilities if there is an endocrinologist who has a particular interest in providing the service.

“This,” she says, “leads to inequitable access to services. We need a state policy that recognises gender-affirming healthcare as an essential service and allows for the initiation of HRT (hormone replacement therapy) at other levels of healthcare facilities such as regional and district hospitals, and routine monitoring (including taking blood samples) and dispensing of medication at primary health care level,” says Beukes.

“We also need a standardised policy framework, with a national policy on the provision of gender-affirming health care, and for both state and private bodies and institutions to adopt the national gender-affirming guidelines (which are currently being drafted).

"The Council for Medical Schemes (CMS) needs to include gender-affirming health care as a prescribed minimum benefit so that it will be covered by medical aids, and when National Health Insurance is introduced, it needs to include gender-affirming health care,” says Beukes.

Department of Health responds

Spokesperson for the National Department of Health, Foster Mohale notes that several structural factors influence the vulnerability of transgender people and this is underscored by social marginalisation, stigma, and discrimination on all levels.

He says that the department recognises that gender reassignment surgery is a vital component of the transition process - from male to female and vice versa. “This is, however, a complex and multi-faceted process that not only includes genital reconstruction surgery but also may include facial feminisation, breast augmentation, and the use of hormones to enhance the body. This is a long-term process and requires medical staff with specialised knowledge and skills to support the path and to ensure optimal results,” he says.

Mohale says transgender people are one of the key populations that the department recognises as at increased risk of HIV acquisition and onward transmission. He says there are clear references to services for transgender people in the National Strategic Plan for HIV, STIs, and TB of 2017-2022, and in the Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI) Strategy .

He says the National Department of Health is currently revising its High Transmission Area programme which has been renamed the Key Populations programme and this is accompanied by a Key Populations Health Implementation Plan as well as plans to establish Key Populations Centres of Excellence.

“The Centres will be established in public health facilities to ensure sensitive and relevant services for all key populations, including transgender people. We have developed a comprehensive Key Populations Competency and Sensitisation Toolkit and it is being rolled out to as many public health facilities, regional training centres, and to many health workers as possible,” he says.

*This article was produced by Spotlight - health journalism in the public interest.

31 Jan 2014

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Wednesday, July 10, 2024

Children and gender reassignment surgery: How young is too young?

Activists and protesters with the National Center for Transgender Equality rally in front of the White House. Picture: AP

Published Apr 24, 2019

London - She made a name for herself writing books for youngsters that tackle issues as broad as child neglect, divorce and mental illness.

Now Dame Jacqueline Wilson has decided to weigh in on one of the most controversial debates of the day.

The 73-year-old said she feels "very, very worried" for children who are about to undergo gender reassignment surgery. She believes they should not be allowed to go through hormone therapy until they are "utterly mature".

She said: "Some people, right from the time that they are toddlers, are aware that something is wrong and they wish that they could be the other sex.

"But I’m also aware that some children feel strongly for a while and then they change their minds." She added: "I think it’s a decision that has to be left a while until you are... certain you know all the actual consequences.

"Where I would be very, very worried is young children taking any kind of drug, hormones or whatever, the long-term effects of which we don’t know."

Dame Jacqueline said, for young children, it’s not "a question of just having your bits lopped off", it is a "serious, difficult surgery" which can have "devastating consequences".

She said that in an ideal world gender reassingment surgery would not even be necessary and that everyone would be able to "act exactly the way they want to but not try to change themselves physically".

Related Topics:

• CIVIL SOCIETY FORUM
• PRIVATE SECTOR FORUM
• GLOBAL FUND CCM
• SA TB CAUCUS

In-depth: The incredibly long wait for gender-affirming surgery for those who can’t pay

Sep 16, 2021 | News

This article was originally published on the News24

In South Africa, gender-affirming care is mostly only available in the big urban centres of provinces such as Gauteng, the Western Cape, KwaZulu-Natal, and the Eastern Cape.

Transgender people from rural areas or provinces where gender-affirming care is not available must travel long distances to the major cities to access these services.

“There are huge waiting lists and a scarcity of surgical expertise in South Africa. In the private sector, it costs hundreds of thousands of Rands while in the public sector, waiting periods are often quoted as being north of two and a half decades,” says Dr Anastacia Tomson, an author and activist focusing on queer and transgender rights.

Dr Kevin Adams, a consultant plastic surgeon who also works at Groote Schuur Hospital, confirms that the  waiting list for gender-affirming surgery is inordinately long.

“The Covid-19 pandemic has meant that we have been unable to do these operations for 18 months,” says Adams. The waiting list for surgery is over 300 patients long and as one operation can take a day, this means that there is a very long waiting list.

“We do not decide which surgery are permitted, but the vast majority of patients want at least one operation. Since the service was started in 2009, the number of patients entering the service has increased exponentially,” he says.

In 2009, Adams says they were seeing four to five new patients every three months and at the beginning of 2020, the number had doubled.

“There has been no increase in the amount of operating time as the service has increased, and therefore the waiting list continues to grow. There is only one surgeon performing these operations at Groote Schuur,” he says.

Dr Simon Pickstone-Taylor is a Child and Adolescent Psychiatrist, and General Adult Psychiatrist. Pickstone-Taylor, who set up the Gender Identity Development Services (GIDS) within the Division of Child and Adolescent Psychiatry at Red Cross Hospital, says the waiting list is generally 25 years for youth and or adults.

“They (trans teens) are on the same list (with adults). Their starting date is when they first consult the Gender Identity Development Service. None of the youth has had top surgery on the state list to date. All those who have had top (or bottom surgery) have had it with parental finance and a very few with medical insurance paying.

“The state only allows very limited funding for these surgeries, thus the long waiting list,” says Pickstone-Taylor. (Top surgery refers to surgery that changes the appearance of the chest, while bottom surgery refers to surgery that alters the genital area.

Trans kids at a disadvantage

The mother of a 17-year-old transgender adolescent, who prefers not to be identified, says unless you live in Cape Town and are lucky enough to be accepted through the Red Cross War Memorial Hospital or Groote Schuur Hospital programme the only way to receive healthcare support is in the private sector.

“It is very expensive. Discovery Health has a pilot programme to support and affirm trans members but it remains limited and the barriers to entry are financially excessive with a lifetime limit of R200 000 in partial payment benefits,” she says.

She says there is no surgery for trans children in the public health system other than a few cases through Red Cross Children’s Hospital and before that is done, parental consent is needed.

Other surgeries tend to only be available to trans people from the age of 18.

“Young trans people do not always want or need surgery. The other social and medical interventions like hormone therapy are the first steps. What is often the case is that trans boys may need top surgery as soon as possible and this is the sort of initial surgery that a trans young person may need to remain alive.

“In South Africa, the only way for a minor to access top surgery will be through parental consent and in most cases at enormous cost in the private sector and then only with a surgeon who is happy to do this surgery,” she says.

She says less invasive surgeries such as  top surgery  are available through the private sector at an enormous cost. “Our son had top surgery at 14. All other surgeries remain an option for trans people and this is a very personal choice. We are researching surgeons in Serbia, Thailand, and the USA,” she says.

According to Pickstone-Taylor, the waiting list for surgery in the public health sector is so long that none of those under 18 would be still under 18 when offered surgery.

“Parents have to pay privately for top surgery and we work as a multi-disciplinary team to support those that want surgery before 18 and have parents who [can] pay for it. We have to ensure that the young person is psychologically prepared and supported enough to cope with surgery.

“Very few transgender male youth are lucky enough to have parents who can afford to pay for top surgery before 18 years old,” says Pickstone-Taylor, adding that their parents are always needed at this assessment.

The mother quoted earlier suggests that many transgender kids and teens are suffering from mental health problems in part because of the limited access to gender-affirming treatment. “This is why over 50% of transgender children try to kill themselves.

The argument we made to Discovery Health to include adolescents in their Pilot programme (it was previously only for adults) included all the clinical reasons but on a straight financial basis it is cheaper to affirm our kids than to have them in psych clinics trying to kill themselves every year,” she says.

Discovery Health had not responded by the time of publication.

But according to the Acting General Manager of Stakeholder Relations at the Council for Medical Schemes (CMS), Mmatsie Mpshane, the council has engaged the Department of Surgery at the University of Cape Town to discuss funding of gender reassignment surgery by medical schemes.

“It was established that the surgery was not [a] predominant and prevailing level of care across the South African public health sector. This implies that it is not Prescribed Minimum Benefit (PMB) level of care and funding thereof is subject to scheme rules, varying across schemes and dependent on [a] member’s benefit option or plan type.

“The CMS does encourage schemes to consider funding of these procedures as part of its yearly rule registration and approval process,” Mpshane tells Spotlight, explaining the PMB review process is ongoing with stakeholders’ inputs and participation. She said submissions relating to improved access to healthcare for all South Africans, especially vulnerable groups, are welcome.

Why access to gender-affirming care matters

Pickstone-Taylor says that 50% of transgender children will try to kill themselves if they do not get appropriate support.

“Children need social transitions,” he says, “for example when they request to change one or more of the following: name and pronouns, toilet change, and sports and school uniform change. If supported and allowed to socially transition, co-existing psycho-pathology invariably disappears the same day for pre-adolescent children.

“Equally, for adolescent children, suicidality and co-existing psycho-pathology disappear rapidly when allowed to take hormones to either stop puberty or cross-sex hormones. They are lifesaving in many cases,” says Pickstone-Taylor.

Chris McLachlan, the chairperson of PATHSA (an interdisciplinary health professional organisation), says studies indicate that Trans and Gender Diverse (TGD) people that are not able to access gender-affirming care have a 42 to 45%  suicidality rate , meaning they would have attempted suicide in their lifetime.

“This [number] comes significantly down once the TGD person was able to access gender-affirming healthcare. Often, TGD people experience  minority stress .

Minority stress, he explains, is the stress that TGD people experience as they navigate a hetero-cisnormative world where they are marginalised, discriminated against, not accepted and affirmed, and even become victims of violence. We find that more TGD people suffer from anxiety and depression and this is often due to, or compounded by, the minority stress,” says McLachlan.

Gender dysphoria

Clinical psychologist, Jordan du Toit says to be trans is associated with a condition called gender dysphoria, and while this is not a mental illness, it relates to the distress a trans person feels when their body does not match their internal sense of their gender.

“Gender dysphoria is associated with increased anxiety around your body and how it is seen by others, distress that your body does not match outwardly how you feel internally, and decreased pleasure in your body for things like sex, exercise, and daily living,” says du Toit.

This, du Toit says is a very traumatic experience to go through, and similar to other invalidating experiences (like sexism, racism, ableism) transphobia can be a real threat to trans individuals’ sense of acceptance and physical safety in the world.

“This can mean trans individuals mask or hide who they are to exist safely in the world or suffer from higher than average anxiety levels related to harassment and transphobia from others.

“The trans community is more at risk of suffering from post-traumatic stress disorder as a result of transphobic attacks, and this has a knock-on effect as it can lead to depression. The LGBTIQAP+ community at large is more at risk for suicide because of abuse and related depression,” says du Toit.

She adds that to be trans can be expensive.

“For a cisgender person (someone whose gender identity matches their biological assigned sex at birth), their bodies produce the hormones needed to maintain a congruent outward appearance.

“For someone who is trans, they need additional support for things like hormone therapy and affirmative surgery to help diminish gender dysphoria,” says du Toit, adding that the struggle to find affordable medical care can increase gender dysphoria and heightens the risk for mental illnesses such as depression.

McLachlan says the mental health risk is higher predominantly due to living in a world that is often unaccepting and also having to navigate a world that is not structured for diversity in gender and diverse gender expression.

“The TGD person needs to navigate an unwelcoming world, needs to navigate so many barriers and gatekeeping in various healthcare structures in order to live freely as the person they are and has to deal with rejection, hate, and marginalisation,” says McLachlan.

Trans persons at higher risk for HIV

A meta-analysis published in  The Lancet  suggests that internationally transgender women are as much as 49 times more likely to contract HIV than adults of reproductive age in general. Since the rate of HIV in adults of reproductive age in South Africa is extremely high, the ratio will be lower here – although that obviously doesn’t preclude the likelihood that South Africa may have some of the world’s highest rates of HIV infection in transgender people.

According to Nelson Dlamini, spokesperson for the South African National AIDS Council (Sanac), HIV risk in transgender women is embedded in multiple co-occurring public health problems.

Speaking to Spotlight, Dlamini says there are high rates of unprotected anal sex among transgender women, which carries a higher risk of HIV transmission than vaginal sex.

“Several factors contribute to this stigma and discrimination, leading to low self-esteem and disempowerment [which] can make it harder for transgender people to insist on condom use. In many settings, condom use is often controlled by the insertive sexual partner, so many transgender women who have sex with men can feel unable to instigate condom use,” he says.

Dlamini further states that “gender-changing hormones, which some transgender women use, can lead to erectile dysfunction, increasing the likelihood of taking the receptive role during sex,” he says, adding that there are other social factors that make transgender people more likely to engage in high-risk sex.

Dlamini says  studies  have shown that some transgender people who want to affirm their gender identity through sex, or who fear rejection from sexual partners can be more likely to agree to unprotected sex.

“Evidence-based multilevel interventions that address the structural, biomedical, and behavioural risks for HIV among transgender populations, including transgender men, are needed to address disparities in HIV prevalence.

“Tailoring HIV testing activities to overcome the unique barriers faced by transgender women and men have increased rates of testing among these populations,” he says.

Towards solutions: Improving health systems

According to Gender Dynamix’s Adriana Beukes, there is a need for resources and sensitising of healthcare providers and administrators.

“There is a dire need for more trained and specialised doctors who can perform  vaginoplasty ,  clitoroplasty  and  labiaplasty  for women, and  hysterectomy  and  oophorectomy , as well as  metoidioplasty  or  phalloplasty ,  scrotoplasty /testicular implants for men,” says Beukes.

Beukes says part of the challenge is a lack of scientifically-based policy and protocols in the public health system which means that gender-affirming care is frequently seen as elective and non-essential, and is often only available at tertiary facilities if there is an endocrinologist who has a particular interest in providing the service.

“This,” she says, “leads to inequitable access to services. We need a state policy that recognises gender-affirming healthcare as an essential service and allows for the initiation of HRT (hormone replacement therapy) at other levels of healthcare facilities such as regional and district hospitals, and routine monitoring (including taking blood samples) and dispensing of medication at primary health care level,” says Beukes.

“We also need a standardised policy framework, with a national policy on the provision of gender-affirming health care, and for both state and private bodies and institutions to adopt the national gender-affirming guidelines (which are currently being drafted).

“The Council for Medical Schemes (CMS) needs to include gender-affirming health care as a prescribed minimum benefit so that it will be covered by medical aids, and when National Health Insurance is introduced, it needs to include gender-affirming health care,” says Beukes.

Department of Health responds

Spokesperson for the National Department of Health, Foster Mohale notes that several structural factors influence the vulnerability of transgender people and this is underscored by social marginalisation, stigma, and discrimination on all levels.

He says that the department recognises that gender reassignment surgery is a vital component of the transition process – from male to female and vice versa. “This is, however, a complex and multi-faceted process that not only includes genital reconstruction surgery but also may include facial feminisation, breast augmentation, and the use of hormones to enhance the body. This is a long-term process and requires medical staff with specialised knowledge and skills to support the path and to ensure optimal results,” he says.

Mohale says transgender people are one of the key populations that the department recognises as at increased risk of HIV acquisition and onward transmission. He says there are clear references to services for transgender people in the  National Strategic Plan  for HIV, STIs, and TB of 2017-2022, and in the Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI)  Strategy .

He says the National Department of Health is currently revising its High Transmission Area programme which has been renamed the Key Populations programme and this is accompanied by a Key Populations Health Implementation Plan as well as plans to establish Key Populations Centres of Excellence.

“The Centres will be established in public health facilities to ensure sensitive and relevant services for all key populations, including transgender people. We have developed a comprehensive Key Populations Competency and Sensitisation  Toolkit  and it is being rolled out to as many public health facilities, regional training centres, and to many health workers as possible,” he says.

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