We support an affirming approach to managing the transgender and gender diverse (TGD) client, centering on the individual’s agency, autonomy and right to self-determination, as opposed to practices that pathologise and stigmatise transgender identity, imposing barriers to accessing healthcare services.

Transgender and gender diverse individuals have long faced discrimination on multiple axes, both globally and in South Africa. Although South Africa enshrines the protection of human rights in its Constitution, TGD individuals continue to face marginalisation, prejudice and threats to their safety. Challenges, including homelessness, unemployment, poor social support, bullying, harassment and violence, persist, indicating failures of policy development, practice implementation and a disregard for the human rights of individuals in the TGD community.

This guideline has been developed primarily with the intention of centering and amplifying voices of TGD individuals in order to facilitate access to healthcare that is sensitive, skilled and respectful. We recognise that there are significant gaps in the knowledge and skills of healthcare providers, and there is a lack of understanding of the unique experiences faced by TGD persons. The prevailing sentiment that many healthcare providers hold around TGD individuals, informed by ignorance and conditioning within social and societal structures, are malevolent towards this community, and often include harmful assumptions and generalisations. We believe that healthcare providers have an ethical obligation to interrogate these notions, and we promote an attitude of respect for diversity that upholds human rights.

It has been well established that access to competent and dignified gender-affirming healthcare (GAHC) is not only safe but also plays a significant role in improving measurable outcomes for TGD clients. It has also been well established that pathologising approaches and practices that limit access to care can be damaging and harmful.

Finally, we recognise that TGD individuals have historically endured being undermined, condescended to and pitied by the healthcare system and its providers. We affirm a commitment to upholding a strength-based perspective that values and respects the experiences of TGD clients and celebrates their individual identity rather than merely accepting or tolerating it.

This guideline, which no doubt will require ongoing revision, reflection and refinement in consultation with TGD communities and healthcare providers, represents a first step made in good faith towards creating a practical tool founded in robust scientific evidence, lodged within a human rights framework, and is intended to facilitate access to skilled and sensitive care that will yield tangible benefits to this unique and important group.

Scope and purpose

Audience

This includes all healthcare providers, particularly those working in a primary care setting, public or private, or that care for TGD clients.

Methods

The guideline development committee comprised 17 people, chaired by Dr Anastacia Tomson and Rev. Chris/tine McLachlan, which was inclusive, with representation of providers, advocates and civil society organisations in the TGD space, and many with personal experience as a TGD client. Development was predicated on the necessity to amplify the voices of those within the TGD community in order to better meet their needs, rather than presuming that healthcare providers can address those needs alone. This guideline was informed by evidence-based research studies, as well as provider experience from within the field. The committee worked from a gender-affirming, non-gatekeeping, depathologising perspective using a participatory approach that centres on the TGD client’s agency and humanity, and upholds their dignity.^1,2,3 Strict values underpin this guideline, as shown in Table 1. In order to ensure applicability to the South African context, focused effort was made to review local research studies. Resources from the global South were then accessed, and only key resources from the global North were incorporated. An extensive, external peer review process was conducted, which included both health provider and community reviews. Guideline development and publication were supported by the Southern African HIV Clinicians’ Society (SAHCS) through Dr Camilla Wattrus and Dr Lauren Jankelowitz.

1. Introduction

South Africa is a country with a progressive Constitution and Bill of Rights that provide for dignity, equality and access to healthcare services.⁷ This is echoed by the South African Health Professions Act and general ethical rules for Health Professionals¹⁸, Social Service Professions,¹⁹ the Constitutions of the Professional Association for Transgender Health in South Africa²⁰ and Psychological Society of South Africa²¹, and the Department of Health’s Batho Pele principles.²² Despite this, many transgender and gender diverse (TGD) individuals struggle to access gender-affirming healthcare (GAHC) services in South Africa.

Gender-affirming healthcare attends holistically to a TGD individual’s mental, physical and social well-being, and health needs, whilst respecting their self-identified gender.²³ Each individual has unique needs, and the gender-affirming process is rarely linear. This process may include social and medical elements, or none at all. A client with a non-binary identity may have unique and specific treatment goals:

It is important to note that as a healthcare provider, withholding or delaying treatment is not a neutral action. It can have an impact on the client’s mental health conditions and, in adolescents, may have implications on what medical or surgical treatment is required later in life. Gatekeeping (delaying treatment until the healthcare provider feels a particular subjective degree of certainty) is potentially harmful.¹¹

2. Informed consent

2.1. The process

Informed consent (IC) in GAHC is complex and nuanced.^25,26 The IC process should empower the individual by upholding their autonomy and maintaining their integrity.¹¹ Even in a supportive and affirming environment, there is often an unequal power relationship between the client and the healthcare provider.²⁷ This can be distressing to the client and have a negative impact on their care.²⁸ The client and healthcare provider should be collaborative partners in decision- making.^1,29 The healthcare provider should inform the client of the risks and benefits of the various treatment options, thus enabling the client to make an informed decision about their own healthcare.³⁰

2.2. Hormone therapy and surgery

A healthcare provider wanting to prescribe hormone therapy (HT) does not require a letter from a mental health provider (MHP) in order to do so, and they may perform the psychosocial assessment themselves if comfortable.^6,26 For gender-affirming surgery, a documented process of thorough IC is essential and, ideally, should be performed together with a multidisciplinary team that includes a MHP. If the client is able to consent, their autonomy should be respected and facilitated,⁶ and it is recommended that in the case of an MHP writing a referral letter to a surgeon, this be written in collaboration with the client.²

We note that the World Professional Association for Transgender Health (WPATH) Standards of Care 7⁶ states that a client should have two independent psychological evaluations prior to surgery. However, it has been convincingly argued that this is not necessary for all clients.³¹

2.3. Children and adolescents

The term ‘medical treatment’ is understood to be a manifestation of the right to health as provided for in Section 27 of the Constitution of the Republic of South Africa,⁷ and includes access to psychosocial and mental healthcare services.³³

If an adolescent desires puberty blocking medication, HT or surgery, the IC process requires involvement of a multidisciplinary team, including both mental health and medical or surgical providers.³⁴ It is recommended that both parents and legal guardians be included in this process wherever possible,⁵ as improved family support is associated with better mental health outcomes in TGD adolescents.^35,36

2.4. Intellectual and developmental disability

Individuals living with intellectual or developmental disability have the right to access healthcare services.³⁷ This includes TGD individuals who may have limited capacity to consent to gender-affirming treatment. Where fully IC cannot be provided, shared decision-making practices should be adopted, in which the client’s autonomy in the process is upheld.³⁸

3. Primary care

3.1. The importance of the primary care provider

The TGD population is a marginalised group that faces many barriers in accessing healthcare services.³⁹ Currently, there are few facilities, resources and targeted programmes to cater for this population’s specific sexual and reproductive health needs.⁴⁰ In order to enable broader access, the provision of GAHC services needs to move away from specialist clinics and into primary care.^41,42 Gender-affirming healthcare should be integrated into existing primary care services, as has been done with HIV care in South Africa. Primary care nurses are in a key position to ensure that TGD clients receive better care and experiences within healthcare facilities.⁴³ Delivery of HT by primary care providers using the IC model can be performed safely and effectively for adult clients, with specialist endocrinologist care needed only for complex cases.⁴⁴ Specialist involvement may also be of great value for an adolescent client; however, case-by-case decisions should be made within a multidisciplinary team context.⁵ In addition, a sex-positive approach by the primary care provider is important. It recognises that each individual’s sexuality is unique and multifaceted, and emphasises the importance of sexual pleasure, freedom and diversity.⁴⁵

3.2. Comprehensive care

Screening is part of prevention and providing comprehensive primary care. When caring for a TGD client, specific attention needs to be paid to the following areas:

3.2.1. Violence

Transgender and gender diverse persons experience a disproportionately high level of violence³⁹ and, therefore, a trauma-informed primary care approach is essential.⁴⁶ The World Health Organization (WHO) recommends the LIVES approach to violence (Listen, Enquire, Validate, Enhance safety and provide Support).⁴⁷ A client who has experienced sexual violence needs timely access to appropriate care, including post-exposure prophylaxis (PEP), sexually transmitted infection (STI) prevention and, if necessary, emergency contraception.⁴⁸

3.2.2. Mental health

Comprehensive care should include screening for mental health conditions, as well as consideration of the possible negative impact of gender dysphoria on the client’s mental health, and the potential positive impact that gender-affirming treatment may have.^49,50 In a South African study, it was found that transgender adults had an incidence of anxiety of 25.9%, of substance use 21.0%, of eating disorders or psychotic disorders 2.3%, and a lifetime prevalence of mood disorder of 21.2%.⁵¹ Assessment should include that of the client’s existing support structure, and support and psychoeducational needs related to their care.

A TGD client should always be offered mental health support,^5,6 and continued support should be encouraged and facilitated, regardless of the client’s mental health status.²⁹

A mental health condition is not a contra-indication to initiating HT, and it can be managed concurrently.⁶ Referral to a MHP is required if there is a concern about decision-making capacity or if a mental health condition needs to be addressed. Whilst the presence of some mental health disorders (particularly those with manic or psychotic features) may have an impact on an individual’s capacity to provide IC, a recent meta-review showed that most clients with a severe mental disorder made appropriate decisions regarding their healthcare.⁵² An Australian study³⁰ revealed that general practitioners needed to refer only 8% of their TGD clients to a mental health professional prior to HT initiation and most of these clients had either schizophrenia or post-traumatic stress disorder (PTSD). Over half (56%) of TGD clients in this study had a mental health condition, such as depression, anxiety, attention-deficit-hyperactivity-disorder, autism-spectrum disorder or bipolar disorder; however, this did not have an impact on their capacity to consent to HT.³⁰

3.2.3. Substance use

Nearly half of transgender women (48%) and transgender men (49%) consume alcohol at hazardous, harmful or dependent levels.³⁹ These harmful drinking practices are associated with a lifetime experience of physical or sexual violence.³⁹ In addition, tobacco, alcohol and drug use can be used as coping mechanisms,⁵³ and tobacco use in combination with oestrogen therapy is associated with an increased risk for venous thromboembolism;⁵ thus, screening is essential. A sensitive, client-centred approach within a harm reduction framework is recommended.⁵⁴

3.2.4. Fertility and contraception

Reliable contraception options must be explored in an assigned-female-at-birth (AFAB) client that has a uterus and ovaries, as pregnancy is still possible, even if the client is on testosterone.⁵⁵

The client’s reproductive preferences should be thoroughly assessed, especially in the context of initiating HT. A transgender man who desires children may consider pregnancy⁵⁶ and chest feeding.⁵⁷ In a transgender woman who wishes to breastfeed, lactation can be induced by expression and medications (such as domperidone) with no adverse effects on the infant.^57,58

3.2.5. Cancer

Cancer screening is based on what anatomy (body part or organ) is present and whether the client meets the criteria for screening based on risk factors and/or symptoms. Relevant screening should be carried out regardless of HT use,⁵⁹ and there is no evidence for increased risk of cancer as a result of HT.⁵⁹

In a TGD client with cervical tissue, cervical screening, human papillomavirus (HPV) testing and HPV vaccination are essential.⁶⁰ In South Africa, cervical cancer ranks as the highest cause of cancer-related deaths in persons AFAB⁶¹, and screening should be performed regardless of the sexual orientation or comorbidities.⁶² This can be performed with a Pap smear or a vaginal HPV swab test. A self-collected vaginal swab is an option for a client who is reluctant to have a vaginal examination.⁶³

In a TGD client with breast tissue, recommendations for breast cancer screening should be followed as for a cisgender person.⁶⁴

Prostate cancer has been documented in transgender women, although the prevalence is lower in transgender women than in cisgender men.⁶⁴ Screening should follow guidelines as for cisgender men; however, if a prostatic-specific antigen (PSA) test is carried out in a transgender woman with a low testosterone level, the upper limit of normal should be reduced to 1.0 ng/mL (rather than 2.0 ng/mL as in cisgender men).⁶⁵

3.2.6. Sexual health

In a client taking feminising HT, changes to libido and sexual response cycle are usually observed within 1–3 months of initiation of treatment.⁶⁶

In a client taking masculinising HT, an increase in sexual desire and activity is often reported⁶⁶, and clitoral enlargement is likely to occur.⁶⁷ Vaginal atrophy may occur because of the hypoestrogenic effect that testosterone has on vaginal tissues⁶⁸ and can be ameliorated with lubricants.

A TGD client on HT may experience a shift in sexual orientation over time.⁶⁹

3.2.7. Sexually transmitted infections

Transgender and gender diverse clients are not a single category. Epidemiologic differences, such as the prevalence of gonorrhoea, require different responses for reducing infection and delivering appropriate sexual healthcare.⁷⁰

A client may engage in high-risk behaviour, and a detailed sexual history should aid screening and examination. Assumptions about the client’s sexual orientation and behaviour should be avoided, and rather discussed in a -non-judgmental way. It is also important to note that in African culture, the thought of sex as taboo limits the range of acceptable terms when discussing a sexual history.⁷¹ The use of culturally respectful language can enable the reporting of truthful facts and minimise ambiguity or shame.⁷² This can be performed jointly with visual aids or a bilingual lexicon when necessary.⁷³ Table 2⁷⁴ provides recommendations for how to take a sexual history and the isiNguni alternatives provided in the table acknowledge respect and personhood-principles, that are largely characterised and embraced by Southern African ethno-cultural populations.

3.2.8. HIV

Transgender and gender diverse persons are disproportionately burdened by HIV and have a greater risk of acquiring the virus, with the prevalence rate of HIV being 46% amongst transgender women in South Africa.⁷⁵ As such, all TGD clients should be offered pre-exposure prophylaxis (PrEP).⁷⁶ PrEP has no impact on the concentration of oestradiol or testosterone levels and can be safely prescribed in a client on HT.⁷⁷ HIV testing and counselling services should address TGD-specific needs, and options, such as HIV self-screening, index testing and partner notification, should be offered.⁵⁹

Modern antiretroviral treatment (ART) and the use of an integrase inhibitor are recommended for a TGD client with HIV, as there are no contraindications to HT.⁷⁸ A dolutegravir-containing regimen is preferred over an efavirenz-containing regimen because it is generally better tolerated (fewer neuropsychiatric, hepatic and metabolic effects) and has a very high resistance barrier.⁷⁹

If the TGD client is on both spironolactone and cotrimoxazole, serum electrolytes and renal function need to be frequently monitored because of a possible drug interaction, which may lead to hyperkalaemia, severe illness and even death.⁸⁰ Particularly close attention should be paid to the client if they are elderly.⁸⁰

Transgender women with HIV are less likely to access HIV treatment or engage in care because of barriers, such as poverty, violence, stigma and unemployment. As such, there are lower rates of virologic suppression and higher HIV-related mortality rates in this group.⁸¹

Adherence to ART and PrEP should be emphasised. Social media platforms and other information communication technologies should be used to encourage retention in HIV care services.⁸²

3.2.9. Physical examination

It is important to note that a physical examination may cause the TGD client distress. Box 1 provides an affirming approach to a physical examination.⁵⁹

4. Non-medical gender-affirming practices

It is important to understand non-medical practices and to establish which strategies the client may use. These strategies are used by TGD individuals to modify their gender presentation, and include binding, tucking, padding and packing.^83,84 These strategies may alleviate gender dysphoria and can address the need to ‘pass’ as cisgender in a particular context.⁸⁴ It is important to understand associated risks and benefits, and provide the client with information on how to perform them safely.

4.1. Binding

Chest binding is used to flatten chest tissue. Specialised compression garments, bandages or duct tape may be used. Although this can be safely performed, risks may include back and shoulder pain, shortness of breath, and skin and soft tissue problems. Recommend ‘off-days’ from binding, encourage good skin hygiene, and advise the client to avoid elastic bandages, duct tape and plastic wraps.⁸⁵

4.2. Tucking

Tucking is used to present a flat pelvic area using a gaff (a specialised tight garment, often homemade), tape or tight briefs.⁸⁶ The testicles are pushed into the inguinal canal, and the penis is taped between the legs.⁸⁷ Although this can be safely carried out, risks may include testicular and penile pain, and skin problems such as a rash and itching.⁸⁶ Recommend tucking for shorter periods or less tight tucking, and good skin hygiene is encouraged.⁵⁹

4.3. Padding and packing

Padding involves the use of prosthetics or padding under the clothes to give the appearance of breasts and/or phenotypic female curves. Packing is the use of prosthetics or padding under the clothes to give the appearance of a penis and phenotypic male pelvic bulge.⁸³ Both padding and packing carry little to no health risk.

5. Psychosocial care

The term ‘mental healthcare provider (MHP)’ has been used, and refers to the broad spectrum of providers who may assist the client with their psychosocial needs.^5,89 These include clinical, counselling, educational and industrial psychologists; clinical, school and other social workers; psychiatrists; psychological and registered counsellors, and occupational therapists.

5.1. The role of the mental healthcare provider

A life-course approach alongside understanding the impact of minority stress, stigma and prejudice on the client’s psychosocial well-being is recommended.^2,88,89 The concerns of the individual, as well as their broader socio-economic-cultural context, should be addressed. The term ‘mental healthcare provider (MHP)’ has been used, which refers to the broad spectrum of providers who may assist the client with their psychosocial needs.^5,89 The MHP has many important roles in aiding gender-affirming care, as displayed in Table 3.

5.2. Children

A child can present as early as 2 or 3 years of age with persistent and consistent indicators of gender diversity.^5,94 The MHP needs to ‘get to know’ the TGD child, and gender incongruence must be determined together with the child and their caregiver(s).^5,6,94 Social transition is the recommended intervention for a TGD child, where it is their expressed need to do so⁶, and this can be facilitated by the MHP.⁹⁷

5.3. Adolescents

The prospect of puberty and developing secondary sexual characteristics in conflict with experienced gender identity is often daunting and even traumatic for a TGD adolescent. The MHP should work with the adolescent and their caregiver(s) and, if appropriate, facilitate access to puberty pausing treatment.^5,6,94,98,99

5.4. Adults

The MHP should offer an affirming and supportive space to enable TGD adults to come to an understanding and acceptance of their gender identity and its possible implications.^3,100 Any trauma experienced as a consequence of the client’s gender identity should be addressed. A client who has begun transitioning within adulthood may require support with ‘coming out’ to their intimate partner(s), family, friends and work colleagues; and managing the resulting relational outcomes.^6,101,102

For an elderly client who may have specific challenges, such as an increased risk of isolation or loneliness, the MHP should help to identify sources of strength and resilience.¹⁰³ The MHP may need to assist in finding a safe and affirming living space with adequate medical and psychosocial care.

5.5. The meso and macro context

A MHP working with a TGD client (child, adolescent or adult) may need to engage with the client’s broader family, learning institution or community to help to establish safe and affirming spaces for the client. This could include supportive counselling, psychoeducation, community education, resource development and linkage, offering a support space and advocacy actions.^3,5,6,94

6. Hormone therapy

6.1. Background

Gender-affirming hormones have been shown to be safe^104,105 and effective,¹¹ and were listed as essential medicines by the South African National Essential Medicine List Committee (NEMLC) in 2019, for tertiary level of care¹⁰⁶. The goal of HT is to affirm the client’s experienced gender.¹⁷ In a non-binary client, it is particularly important to understand their desired outcome before deciding on treatment.¹⁰⁷ Provision of HT should be based on the principle of IC, rather than on the specific diagnostic criteria that have previously, and often harmfully, been applied.¹¹

6.2. Indications

Figure 1 shows a visual representation of the recommended process to follow when providing HT.

6.3. Feminising therapy

The aim of therapy is to promote the development of feminising sexual characteristics and to suppress the masculinising effects of endogenous testosterone.¹⁰⁹ The cornerstone of treatment is administration of exogenous oestrogen. The addition of an androgen receptor antagonist may be required to achieve full suppression of testosterone¹¹⁰; however, recent evidence suggests that this may not be essential to reduce testosterone levels to cisgender female ranges, as was previously thought.¹¹¹ For conditions that may be exacerbated by oestrogen administration, such as oestrogen-sensitive malignancies, coronary artery disease and cerebrovascular disease, careful evaluation should be done prior to HT initiation⁶⁶ and HT individualised. In a client with a history of venous thromboembolism (VTE), transdermal oestrogen may be considered after an IC discussion.^59,112

Feminising treatment options are shown in Table 4, and effects and reversibility of treatment are shown in Table 5¹²⁶. Baseline screening is recommended prior to HT treatment, as shown in Figure 2¹²⁷.

A client’s experience on treatment should be the primary guiding factor in dose titration and maintenance, and treatment may still be provided in resource-constrained settings where laboratory measurement of hormonal levels is not available. However, when these investigations are accessible, they can provide helpful guidance in optimising the dose. Recommended laboratory monitoring is shown in Table 6⁵⁹.

6.4. Masculinising therapy

The goal of masculinising therapy is to promote the development of testosterone-induced secondary sexual characteristics.¹²⁸ Suppression of oestrogen and ovulation will almost always occur¹⁰⁸ and, thus, oestrogen antagonists are not required.

Exogenous testosterone can be administered by intramuscular or subcutaneous injection or as a topical transdermal preparation. Oral testosterone should be avoided as it is hepatotoxic.⁶⁷ A client with severe hypertension, sleep apnoea or untreated polycythaemia (haematocrit above 55%) requires management prior to treatment initiation, as these conditions may be exacerbated by testosterone.⁶⁶ Testosterone treatment options are shown in Table 7^66,129, whilst effects and reversibility of treatment are shown in Table 8^66,109. Baseline screening and monitoring are recommended, as indicated in Figure 2 and Table 6, respectively.

6.5. Adolescents

Whilst HT is not required for prepubertal TGD children, pubertal suppression to halt the progression of physical changes may significantly reduce distress in a TGD adolescent,^94,108 which, in turn, has been shown to improve mental health conditions and decrease suicidality.¹³⁰ Puberty can be suppressed with gonadotrophin-releasing hormone agonists (GnRHa) once Tanner Stage 2 of puberty has been reached.⁹⁴ Gonadotrophin-releasing hormone agonists available in South Africa include leuprolide and goserelin, both of which are administered every 12 weeks via intramuscular or subcutaneous injection.¹³¹ It is recommended that a paediatric endocrinologist oversees this care,^5,108 and that fertility preservation is discussed prior to HT initiation.¹³² The timing of HT initiation should be individualised, and should consider family support, likely time on GnRHa, potential impacts on height, risks of delaying HT and the adolescent’s ability to consent.⁹⁴ The inclusion of an MHP and, ideally, the parents or legal guardians are recommended when deciding on the appropriateness of HT.⁵

6.6. Mature clients

Hormone therapy is indicated as a long term treatment, as some body changes may reverse if it is stopped.⁵⁹ There is no age recommendation for the reduction or termination of HT, and individual cardiovascular risk in the mature TGD client needs to be considered and discussed with the client.⁵⁹

7. Surgery

7.1. Preoperative considerations

It is important to note that there is diversity in the surgery requested by TGD clients.¹³³ A client may desire for chest or facial or genital surgery only, or a combination of these. A non-binary client’s request for surgery should be specifically individualised.¹³⁴ Tables 9 and 10 show, respectively, the available feminising and masculinising surgical options. Hormone therapy is usually recommended prior to surgery; however, a client may be unable to or prefer not to take HT prior to surgery.⁶ In South Africa, a documented process of thorough IC is essential prior to surgery.

7.2. Peri-surgical care

Post-surgical care is vital to recovery, and should include psychological care and physiotherapy. It is important to note that the continuity of gender-affirming care does not end with the surgical procedure(s), and ongoing support should be provided. The TGD community can play a significant role in perioperative care, both through peer and organisational support groups.¹⁴⁰ Satisfaction following surgery is usually high, with less gender dysphoria, reduced psychological distress and better integration into society.¹⁴¹

8. Institutions

8.1. Care facilities

Providing a safe, welcoming, and culturally appropriate healthcare environment is essential to ensure that a TGD client not only seeks care but also returns for follow-up.⁵⁹

The following are recommendations for care facilities, including healthcare facilities,^142,143 old-age homes¹⁰³ and shelters¹⁴⁴:

8.2. Correctional facilities

8.3. Work facilities

Inclusion begins before a TGD staff member’s social transition within the workplace. Collaboration between leadership and human resources is needed for the implementation of clear guidance to support TGD staff.¹⁴⁹ Healthcare providers can play an advisory role in needs assessment, intervention design and implementation, and policy development and employee benefits.

8.4. Educational facilities

In accordance with South African legislation, all schools, whether private or public, mixed or single gender, must ensure an inclusive, non-discriminatory and diversity-affirming environment.^150,151,152 This supports basic human rights, actualisation of potential, human dignity, equality, right to education, protection from physical and emotional harm, and is in the best interest of the learners. Healthcare providers can assist schools with the development of relevant policies and guidelines, as well as staff sensitisation.³

9. Voice and communication

It is helpful to understand how sex and gender influence voice and communication, and that a speech-language therapist (SLT) can play an important role in this regard.⁶ Voice and communication are often closely connected to gender identity or expression, and the TGD client may want to sound more feminine, more masculine or gender neutral.

Masculinising HT can contribute to a desired voice change but may not be sufficient to achieve the client’s goals. Feminising HT is unlikely to result in a desired voice change. The TGD client, therefore, may benefit from referral to a qualified SLT with experience in providing gender-affirming care.⁶ The main strategy for voice care is related to the alteration of one’s speaking fundamental frequency, intonation and resonance.^153,154

The SLT should perform a voice and communication assessment, which includes a quality of life measure,^155,156 and can provide both voice and communication interventions, as shown in Table 11. It is important to acknowledge South Africa’s multilingual communication landscape, and that communication requires an individualised approach and specialist intervention.

10. Key terms

Acknowledgements

The authors would like to acknowledge the contributors involved in the peer review process: Casey Blake, Pierre Brouard, Marli Conradie-Smit, Jenna-Lee de Beer-Procter, Diana Dickinson, Jenny Durandt, Kerry Frizelle, Gerhard Grobler, Naomi Hill, Kim Lithgow, Adele Marais, Sakhile Msweli, Lavanya Naidoo, Tammy Nash, Juan Nel, Simon Pickstone-Taylor, Suntosh Pillay, Alicia Porter, Ian Ross, Andrew Scheibe, Jireh Serfontein, Ariane Spitaels, Liesl Theron, John Torline, Leigh Ann van der Merwe, Niel Victor and Lee-Anne Walker. A special note of thanks also goes to Valencia Malaza from SAHCS for administrative support.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this research article.

To the fullest extent permitted by law, the Southern African HIV Clinicians’ Society (SAHCS) and the authors of this study cannot be held liable for any aspect of healthcare administered using this information or any other use, including any use that is not in accordance with any guidelines or (mis-)use. Specific recommendations provided here are intended only as a guide to clinical management based on expert consensus and best current evidence at the date of first publication. Management decisions for clients should be made by their responsible clinicians, with due consideration for individual circumstances and various contexts. The information provided in this document should not be considered as a substitute for such professional judgement. The most current version of this document should always be consulted.

The authors received no financial support for the research, authorship or publication of this article.

Data sharing is not applicable to this article, as no new data were created or analysed in this study.

This research article followed all ethical standards for research without any direct contact with human or animal subjects.

References

McLachlan C. Gender-affirming healthcare: Our ethical response. HIV Nurs Matters. 2020;11:8–9.
McLachlan C, Nel JA, Pillay SR, Victor CJ. The Psychological Society of South Africa’s guidelines for psychology professionals working with sexually and gender-diverse people: Towards inclusive and affirmative practice. S Afr J Psychol. 2019;49(3):314–324. https://doi.org/10.1177/0081246319853423
Practice guidelines for psychology professionals working with sexually and gender-diverse people. Johannesburg: Psychological Society of South Africa; 2017.
Koch JM, McLachlan C, 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
Oliphant J, Veale J, Macdonald J, et al. Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa New Zealand. Hamilton: Transgender Health Research Lab, University of Waikato; 2018.
Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7, Int J Transgend. 2012;13(4):165–232. https://doi.org/10.1080/15532739.2011.700873
Constitution of the Republic of South Africa Act No. 108 of 1996, South Africa: Government Printers; 1996 [cited 2021 Aug 12]. Available from: https://www.gov.za
Yogyakarta Principles. TheYogyakarta Principles on the application of international human rights law in relation to sexual orientation and gender identity [homepage on the Internet]. Yogyakarta; 2007 [2021 Aug 12]. Available from: http://www.yogyakartaprinciples.org
Yogyakarta Principles. The Yogyakarta Principles Plus 10: Additional principles and state obligations on the application of international human rights law in relation to sexual orientation, gender identity, gender expression and sex characteristics, to complement the Yogyakarta Principles [homepage on the Internet]. 2017 [2021 Aug 12]. Available from: http://www.yogyakartaprinciples.org/principles-en/yp10/
Deutsch MB. Use of the informed consent model in the provision of cross-sex hormone therapy: A survey of the practices of selected clinics. Int J Transgend. 2012;13(3):140–146. https://doi.org/10.1080/15532739.2011.675233
Tomson A. Gender-affirming care in the context of medical ethics–gatekeeping v. informed consent. S Afr J Bioeth Law. 2018;11(1):24–28. https://doi.org/10.7196/SAJBL.2018.v11i1.00616
Chisale SS. Ubuntu as care: Deconstructing the gendered Ubuntu. Verbum et Ecclesia. 2018;39(1):1–8. https://doi.org/10.4102/ve.v39i1.1790
Müller A. Health for all? Sexual orientation, gender identity, and the implementation of the right to access to health care in South Africa. Health Hum Rights. 2016;18(2):195.
Müller A. Professionalism is key in providing services to lesbian, gay, bisexual, transgender and intersex South Africans. S Afr Med J. 2014;104(8):558–559. https://doi.org/10.7196/SAMJ.8447
Department of Public Service and Administration. Batho Pele - ‘People First’, White paper on transforming public service deliver [serial online]. Pretoria: Government Gazette; 1997 [updated 18 September 1997; cited 2021 Aug 12]. Available at: https://www.dpsa.gov.za/dpsa2g/documents/acts&regulations/frameworks/white-papers/transform.pdf
Riggle ED, Rostosky SS, McCants LE, Pascale-Hague D. The positive aspects of a transgender self-identification. Psychol Sex. 2011;2(2):147–158. https://doi.org/10.1080/19419899.2010.534490
Benestad E. From gender dysphoria to gender euphoria: An assisted journey. Sexologies. 2010;19(4):225–231. https://doi.org/10.1016/j.sexol.2010.09.003
DoH. Health Professions Act 56 of 1974. Ethical rules of conduct for practitioners registered under the health professions act, 1974. Pretoria: South African Department of Health; 2006.
Social Service Professions Act 110 of 1978 (Previous short title, ‘Social and Associated Workers Act’, substituted by s. 17 of Act 48 of 1989, and then short title ‘Social Work Act’ substituted by s. 24 of Act 102 of 1998) [assented to 20 June 1978] [date of commencement: 1 Sept 1979]. Pretoria: South African Government; 1978 [cited 2021 Aug 21]. Avaliable from: http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Law_reform/SocialServiceProfessionsAct.pdf
Professional Association for Transgender Health South Africa (PATHSA). Constitution. 2020 [cited 2021 Aug 21]. Available from: https://pathsa.org.za/constitution
Constitution of the Psychological Society of South Africa. Constitution for psychological professionals [homepage on the Internet]. Psychological Society of South Africa (PsySSA); 2012 [cited 2021 Aug 12]. Available from: https://www.psyssa.com/about-us/psyssa-constitution/
Public Service Commission. Report on the implementation of the Batho Pele principle of Openness and Transparency in the Public Service. Pretoria: Public Service Commission (PSC); 2008 [cited 2021 Aug 21]. Available from: https://www.psc.gov.za
Reisner SL, Radix A, Deutsch MB. Integrated and gender-affirming transgender clinical care and research. J Acquir Immune Defic Syndr. 2016;72(Suppl 3):S235–S242. https://doi.org/10.1097/QAI.0000000000001088
Trans rural narratives [homepage on the Internet]. Gender Dynamix; 2020 [cited 2021 Aug 12]. Available from: https://www.genderdynamix.org.za/community-access-to-direct-services
Toivonen KI, Dobson KS. Ethical issues in psychosocial assessment for sex reassignment surgery in Canada. Can Psychol. 2017;58(2):178. https://doi.org/10.1037/cap0000087
Ashley F, St Amand CM, Rider G. The continuum of informed consent models in transgender health. Fam Pract. 2021;8:1–2.
Eales OO, Smith S. Do socio-economically disadvantaged patients prefer shared decision-making? S Afr Fam Pract. 2021;63(1):a5293. https://doi.org/10.4102/safp.v63i1.5293
Newman-Valentine D, Duma S. Injustice to transsexual women in a hetero-normative healthcare system. Afr J Prim Health Care Fam Med. 2014;6(1):1–5. https://doi.org/10.4102/phcfm.v6i1.574
Schulz SL. The informed consent model of transgender care: An alternative to the diagnosis of gender dysphoria. J Humanist Psychol. 2018;58(1):72–92.
Spanos C, Grace JA, Leemaqz SY, et al. The informed consent model of care for accessing gender-affirming hormone therapy is associated with high patient satisfaction. J Sex Med. 2021;18(1):201–208. https://doi.org/10.1016/j.jsxm.2020.10.020
Bouman WP, Richards C, Addinall R, et al. Yes and yes again: Are standards of care which require two referrals for genital reconstructive surgery ethical? Sex Relationsh Ther. 2014;29(4):377–389.
South African Government Childrens Act No. 38 of 2005. Pretoria: South African Government; 2005 [cited 2021 Aug 21]. Available from: https://justice.gov.za
Flisher AJ, Dawes A, Kafaar Z, et al. Child and adolescent mental health in South Africa. J Child & Adolesc Ment Health. 2012;24(2):149–161. https://doi.org/10.2989/17280583.2012.735505
Boskey ER, Johnson JA, Harrison C, et al. Ethical issues considered when establishing a pediatrics gender surgery center. Pediatrics. 2019;143(6):e20183053.
Veale J, Byrne J, Tan KK, et al. Counting Ourselves: The health and wellbeing of trans and non-binary people in Aotearoa New Zealand. Hamilton: Transgender Health Research Lab, University of Waikato; 2019.
Katz-Wise SL, Ehrensaft D, Vetters R, Forcier M, Austin SB. Family functioning and mental health of transgender and gender-nonconforming youth in the trans teen and family narratives project. J Sex Res. 2018;55(4–5):582–590.
Capri C, Abrahams L, McKenzie J, et al. Intellectual disability rights and inclusive citizenship in South Africa: What can a scoping review tell us? Afr J Disabil. 2018;7(1):1–17. https://doi.org/10.4102/ajod.v7i0.396
National Institute for Health and Care Excellence (NICE). Mental health problems in people with learning disabilities: Prevention, assessment and management [homepage on the Internet]. NICE guideline [NG54]. 2016 [cited 2021 Aug 12]. Available from: https://www.nice.org.uk/guidance/ng54/resources/mental-health-problems-in-people-with-learning-disabilities-prevention-assessment-and-management-pdf-1837513295557
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 East and Southern Africa: Research report based on a community-led study in nine countries [homepage on the Internet]. Amsterdam: COC Netherlands; 2019. Available from: http://www.ghjru.uct.ac.za/sites/default/files/image_tool/images/242/PDFs/Dynamic_feature/SOGIE%20and%20wellbeing_07_South%20Africa.pdf
Luvuno Z, 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
Reisner SL, Bradford J, Hopwood R, et al. Comprehensive transgender healthcare: The gender affirming clinical and public health model of Fenway Health. J Urban Health. 2015;92(3):584–592.
Wylie K, Knudson G, Khan SI, Bonierbale M, Watanyusakul S, Baral S. Serving transgender people: Clinical care considerations and service delivery models in transgender health. Lancet. 2016;388(10042):401–411.
Luvuno Z, Ncama B, Mchunu G. Knowledge, attitudes and practices of health care workers related to treatment and care of transgender patients: A qualitative study in Kwazulu-Natal, South Africa. Gend Behav. 2017;15(2):8694–8706.
Shires DA, Stroumsa D, Jaffee KD, Woodford MR. Primary care providers’ willingness to continue gender-affirming hormone therapy for transgender patients. Fam Pract. 2018;35(5):576–581. https://doi.org/10.1093/fampra/cmx119
Williams D, Thomas J, Prior E, Walters W. Introducing a multidisciplinary framework of positive sexuality. Journal of Positive Sexuality. 2015;1(1):6–11.
Machtinger EL, Cuca YP, Khanna N, Rose CD, Kimberg LS. From treatment to healing: The promise of trauma-informed primary care. Womens Health Issues. 2015;25(3):193–197. https://doi.org/10.1016/j.whi.2015.03.008.
World Health Organization (WHO). Health care for women subjected to intimate partner violence or sexual violence: A clinical handbook; 2016 [cited 2021 Aug 12]. Available from: http://apps.who.int/iris/bitstream/handle/10665/136101/WHO_RHR_14.26_eng.pdf;sequence=1
World Health Organization (WHO). Policy brief: Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations; 2017 [cited 2021 Aug 12]. Available from: http://apps.who.int/iris/bitstream/handle/10665/136101/WHO_RHR_14.26_eng.pdf;sequence=1
Oransky M, Burke EZ, Steever J. An interdisciplinary model for meeting the mental health needs of transgender adolescents and young adults: The Mount Sinai Adolescent Health Center approach. Cogn Behav Pract. 2019;26(4):603–616. https://doi.org/10.1016/j.cbpra.2018.03.002
Golden RL, Oransky M. An intersectional approach to therapy with transgender adolescents and their families. Archiv Sex Behav. 2019;48(7):2011–2025.
Grobler GP. The lifetime prevalence of psychiatric diagnoses in an academic gender reassignment service. Curr Opin Psychiatry. 2017;30(6):391–395. https://doi.org/10.1186/s12888-020-02756-0
Calcedo-Barba A, Fructuoso A, Martinez-Raga J, Paz S, De Carmona MS, Vicens E. A meta-review of literature reviews assessing the capacity of patients with severe mental disorders to make decisions about their healthcare. BMC Psychiatry. 2020;20(1):1–14.
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
Scheibe A, Goodman Sibeko SS, Rossouw T, Zishiri V, Venter WD. Southern African HIV Clinicians Society guidelines for harm reduction. South Afr J HIV Med. 2020;21(1):1161. https://doi.org/10.4102/sajhivmed.v21i1.1161
Nisly NL, Imborek KL, Miller ML, Kaliszewski SD, Williams RM, Krasowski MD. Unique primary care needs of transgender and gender non-binary people. Clin Obstet Gynecol. 2018;61(4):674–686.
Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120–1127.
MacDonald TK. Lactation care for transgender and non-binary patients: Empowering clients and avoiding aversives. J Hum Lact. 2019;35(2):223–226. https://doi.org/10.1177/0890334419830989
Paynter MJ. Medication and facilitation of transgender women’s lactation. J Hum Lact. 2019;35(2):239–243.
Deutsch MB. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. San Francisco, CA: University of California; 2016.
Botha M, Dreyer G. Guidelines for cervical cancer screening in South Africa. S Afr J Gynaecol Oncol. 2017;9(1):8–12.
Bruni L, Albero G, Serrano B, et al. Human papillomavirus and related diseases in the world Summary Report. Barcelona: ICO/IARC information centre on HPV and cancer (HPV information centre). 2019 [cited 2021 Aug 12];17. Available from: https://hpvcentre.net/statistics/reports/XWX.pdf
Mohr S, Gygax LN, Imboden S, Mueller MD, Kuhn A. Screening for HPV and dysplasia in transgender patients: Do we need it? Eur J Obstet Gynecol Reprod Biol. 2021;260:177–182. https://doi.org/10.1016/j.ejogrb.2021.03.030
Reisner SL, Deutsch MB, Peitzmeier SM, et al. Test performance and acceptability of self-versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients. PLoS One. 2018;13(3):e0190172.
Joint R, Chen Z, Cameron S. Breast and reproductive cancers in the transgender population: A systematic review. BJOG. 2018;125(12):1505–1512.
Trum HW, Hoebeke P, Gooren LJ. Sex reassignment of transsexual people from a gynecologist’s and urologist’s perspective. Acta Obstet Gynecol Scand. 2015;94(6):563–567. https://doi.org/10.1111/aogs.12618
T’Sjoen G, Arcelus J, De Vries AL, et al. European Society for Sexual Medicine position statement Assessment and hormonal management in adolescent and adult trans people, with attention for sexual function and satisfaction. J Sex Med. 2020;17(4):570–584.
Kirisawa T, Ichihara K, Sakai Y, Morooka D, Iyoki T, Masumori N. Physical and psychological effects of gender-affirming hormonal treatment using intramuscular testosterone enanthate in Japanese transgender men. Sex Med. 2021;9(2):100306.
Schwartz AR, Russell K, Gray BA. Approaches to vaginal bleeding and contraceptive counseling in transgender and gender nonbinary patients. Obstet Gynecol. 2019;134(1):81–90. https://doi.org/10.1097/AOG.0000000000003308
Galupo MP, Henise SB, Mercer NL. ‘The labels don’t work very well’: Transgender individuals’ conceptualizations of sexual orientation and sexual identity. Int J Transgend. 2016;17(2):93–104.
Callander D, Cook T, Read P, et al. Sexually transmissible infections among transgender men and women attending Australian sexual health clinics. Med J Aust. 2019;211(9):406–411. https://doi.org/10.5694/mja2.50322
Mavhandu-Mudzusi A, Netshandama V, Matshidze P. Deconstructing matula (taboo), a multi-stakeholder narrative about LGBTI. S Afr J High Educ. 2017;31(4):307–324. https://doi.org/10.20853/31-4-1328
Duby Z, Hartmann M, Mahaka I, et al. Lost in translation: Language, terminology, and understanding of penile–anal intercourse in an HIV prevention trial in South Africa, Uganda, and Zimbabwe. J Sex Res. 2016;53(9):1096–1106. https://doi.org/10.1080/00224499.2015.1069784
Ramirez CB, Mack N, Friedland B. A toolkit for developing bilingual lexicons for international HIV prevention clinical trials. Population Council and FHI 360; 2013. https://doi.org/10.31899/hiv10.1002
Stroumsa D, Wu JP. Welcoming transgender and nonbinary patients: Expanding the language of “women’s health”. Am J Obstet Gynecol. 2018;219(6):585.e5. https://doi.org/10.1016/j.ajog.2018.09.018
Cloete A, Wabiri N, Savva H, Van der Merwe L, Simbayi L. The Botshelo Ba Trans study: Results of the first HIV prevalence survey conducted amongst transgender women (TGW) in South Africa [homepage on the Internet]. 2019. Available from: http://repository.hsrc.ac.za/handle/20.500.11910/14780
Bekker L-G, Brown B, Joseph-Davey D, et al. Southern African guidelines on the safe, easy and effective use of pre-exposure prophylaxis: 2020. South Afr J HIV Med. 2020;21(1):a1152. https://doi.org/10.4102/sajhivmed.v21i1.1152
Grant RM, Pellegrini M, Defechereux PA, et al. Sex hormone therapy and tenofovir diphosphate concentration in dried blood spots: Primary results of the iBrEATHe study. Clin Infect Dis. 2020;ciaa1160. https://doi.org/10.1093/cid/ciaa1160
Badowski ME, Britt N, Huesgen EC, et al. Pharmacotherapy considerations in transgender individuals living with human immunodeficiency virus. Pharmacotherapy. 2021;41(3):299–314.
Nel J, Dlamini S, Meintjes G, et al. Southern African HIV Clinicians Society guidelines for antiretroviral therapy in adults: 2020 update. South Afr J HIV Med. 2020;21(1):1–39.
Antoniou T, Gomes T, Mamdani MM, et al. Trimethoprim-sulfamethoxazole induced hyperkalaemia in elderly patients receiving spironolactone: Nested case-control study. BMJ. 2011;343:d5228. https://doi.org/10.1136/bmj.d5228
Radix A, Sevelius J, Deutsch MB. Transgender women, hormonal therapy and HIV treatment: A comprehensive review of the literature and recommendations for best practices. J Int AIDS Soc. 2016;19:20810. https://doi.org/10.7448/IAS.19.3.20810
Daniels J, Lane T, Struthers H, et al. Assessing the feasibility of smartphone apps for HIV-care research with MSM and transgender individuals in Mpumalanga, South Africa. J Int Assoc Provid AIDS Care. 2017;16(5):433–439.
Ngoc M-AT, Greenberg K, Alio PA, McIntosh S, Baldwin C. 165. Non-medical body modification (Body-Mod) strategies among Transgender and Gender Diverse (TG/GD) adolescents and young adults. J Adolesc Health. 2020;66(2):S84. https://doi.org/10.1016/j.jadohealth.2019.11.168
Decker M. Minority stress, risky behaviors, and sexual scripting among transgender college students: A mixed methods study [homepage on the Internet]. 2019. Available from: https://thescholarship.ecu.edu/bitstream/handle/10342/7426/DECKER-DOCTORALDISSERTATION-2019.pdf?sequence=1&isAllowed=y
Peitzmeier S, Gardner I, Weinand J, Corbet A, Acevedo K. Health impact of chest binding among transgender adults: A community-engaged, cross-sectional study. Cult Health Sex. 2017;19(1):64–75. https://doi.org/10.1080/13691058.2016.1191675
Poteat T, Malik M, Cooney E. 2148 Understanding the health effects of binding and tucking for gender affirmation. J Clin Transl Sci. 2018;2(S1):76.
Farrier S. International influences and drag: Just a case of tucking or binding? Theatre Dance Perform Train. 2017;8(2):171–187. https://doi.org/10.1080/19443927.2017.1317657
Riggs DW, Treharne GJ. Decompensation: A novel approach to accounting for stress arising from the effects of ideology and social norms. J Homosex. 2017;64(5):592–605.
Reisner SL, Poteat T, Keatley J, et al. Global health burden and needs of transgender populations: A review. Lancet. 2016;388(10042):412–436. https://doi.org/10.1177/0081246314533634
Laher S, Cockcroft K. Psychological assessment in post-apartheid South Africa: The way forward. S Afr J Psychol. 2014;44(3):303–314.
Barker P, Chang J. Basic family therapy. 3rd ed. Hoboken, New Jersey: John Wiley & Sons; 2013 [cited 2021 Aug 12]. Available from: https://doi.org/10.1002/9781118624944
World Health Organization (WHO). ICD-11 for mortality and morbidity statistics. Geneva: WHO; 2018; p. 22. Available from: https://icd.who.int/dev11/l-m/en
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5^®). Washington, DC: American Psychiatric Association; 2013.
Telfer MM, Tollit MA, Pace CC, Pang KC. Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents. Med J Aust. 2018;209(3):132–136. https://doi.org/10.5694/mja17.01044
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(1):1–10. https://doi.org/10.1186/s12914-017-0124-4
Alteration of Sex Discrimination Act. No 49 of 2003. Republic of South Africa: Goverment Gazette; 2003.
Durwood L, McLaughlin KA, Olson KR. Mental health and self-worth in socially transitioned transgender youth. J Am Acad Child Adolesc Psychiatry. 2017;56(2):116.e2–123.e2. https://doi.org/10.1016/j.jaac.2016.10.016
The Professional Association for Transgender Health South Africa (PATHSA) position statement on gender-affirming healthcare for transgender and gender diverse children and adolescents [homepage on the Internet]. The Professional Association for Transgender Health South Africa (PATHSA); 2020. Available from: https://pathsa.org.za/Documents/10679096
Response to the Bell vs. Tavistock judgement [homepage on the Internet]. Professional Association for Transgender Health, South Africa (PATHSA); 2021 [cited 2021 Aug 12]. Available from: https://pathsa.org.za/News/10675745
Applegarth G, Nuttall J. The lived experience of transgender people of talking therapies. Int J Transgend. 2016;17(2):66–72. https://doi.org/10.1080/15532739.2016.1149540
Bockting WO, Knudson G, Goldberg JM. Counseling and mental health care for transgender adults and loved ones. Int J Transgend. 2006;9(3–4):35–82.
Ellis AE. Providing trauma-informed affirmative care: Introduction to special issue on evidence-based relationship variables in working with affectional and gender minorities. Pract Innov. 2020;5(3):179. https://doi.org/10.1037/pri0000133
Porter KE, Brennan-Ing M, Chang SC, et al. Providing competent and affirming services for transgender and gender nonconforming older adults. Clin Gerontol. 2016;39(5):366–388.
Wierckx K, Van Caenegem E, Schreiner T, et al. Cross-sex hormone therapy in trans persons is safe and effective at short-time follow-up: Results from the European network for the investigation of gender incongruence. J Sex Med. 2014;11(8):1999–2011.
Weinand JD, Safer JD. Hormone therapy in transgender adults is safe with provider supervision; a review of hormone therapy sequelae for transgender individuals. J Clin Transl Endocrinol. 2015;2(2):55–60. https://doi.org/10.1016/j.jcte.2015.02.003
Department of Health. National Essential Medicines List Committee. Tertiary and Quaternary level essential medicines list. December 2019. Republic of South Africa: Department of Health; 2019.
Cocchetti C, Ristori J, Romani A, Maggi M, Fisher AD. Hormonal treatment strategies tailored to non-binary transgender individuals. J Clin Med. 2020;9(6):1609.
Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–3903. https://doi.org/10.1210/jc.2017-01658
Safer JD, Tangpricha V. Care of transgender persons. N Engl J Med. 2019;381(25):2451–2460.
Angus LM, Nolan BJ, Zajac JD, Cheung AS. A systematic review of antiandrogens and feminization in transgender women. Clin Endocrinol. 2021;94(5):743–752. https://doi.org/10.1111/cen.14329
Cunha FS, Domenice S, Sircili MHP, Mendonca BBD, Costa EMF. Low estrogen doses normalize testosterone and estradiol levels to the female range in transgender women. Clinics. 2018;73:e86.
Shatzel JJ, Connelly KJ, DeLoughery TG. Thrombotic issues in transgender medicine: A review. Am J Hematol. 2017;92(2):204–208. https://doi.org/10.2147/JBM.S166780
Goldstein Z, Khan M, Reisman T, Safer JD. Managing the risk of venous thromboembolism in transgender adults undergoing hormone therapy. J Blood Med. 2019;10:209.
Glintborg D, T’Sjoen G, Ravn P, Andersen MS. Management of endocrine disease: Optimal feminizing hormone treatment in transgender people. Eur J Endocrinol. 2021;185(2):R49–R63. https://doi.org/10.1530/EJE-21-0059
Randolph JF. Gender-affirming hormone therapy for transgender females. Clin Obstet Gynecol. 2018;61(4):705–721.
Hamidi O, Davidge-Pitts CJ. Transfeminine hormone therapy. Endocrinol Metab Clin North Am. 2019;48(2):341–355. https://doi.org/10.1016/j.ecl.2019.02.001
Leinung MC, Feustel PJ, Joseph J. Hormonal treatment of transgender women with oral estradiol. Transgend Health. 2018;3(1):74–81.
Angus L, Leemaqz S, Ooi O, et al. Cyproterone acetate or spironolactone in lowering testosterone concentrations for transgender individuals receiving oestradiol therapy. Endocr Connect. 2019;8(7):935–940. https://doi.org/10.1530/EC-19-0272
Meyer G, Mayer M, Mondorf A, Fluegel AK, Herrmann E, Bojunga J. Safety and rapid efficacy of guideline-based gender-affirming hormone therapy: An analysis of 388 individuals diagnosed with gender dysphoria. Eur J Endocrinol. 2020;182(2):149–156.
Kuijpers SM, Wiepjes CM, Conemans EB, Fisher AD, T’Sjoen G, Den Heijer M. Toward a lowest effective dose of cyproterone acetate in trans women: Results from the ENIGI study. J Clin Endocrinol Metab. 2021;dgab427. https://doi.org/10.1210/clinem/dgab427
Gooren LJ. Care of transsexual persons. N Engl J Med. 2011;364(13):1251–1257. https://doi.org/10.1056/NEJMcp1008161
Millington K, Williams C. Transgender care. In: Takara S, Madhusmita M, editors. Endocrine conditions in pediatrics. New York: Springer, 2021; p. 357–363.
Cirrincione LR, Huang KJ. Sex and gender differences in clinical pharmacology: Implications for transgender medicine. Clin Pharmacol Ther. 2021:1–12. https://doi.org/10.1002/cpt.2234
Maheshwari A, Nippoldt T, Davidge-Pitts C. An approach to non-suppressed testosterone in transgender women receiving gender affirming feminizing hormonal therapy. J Endocr Soc. 2021;5(9):bvab068. https://doi.org/10.1210/jendso/bvab068
Neyman A, Fuqua JS, Eugster EA. Bicalutamide as an androgen blocker with secondary effect of promoting feminization in male-to-female transgender adolescents. J Adolesc Health. 2019;64(4):544–546. https://doi.org/10.1016/j.jadohealth.2018.10.296
Tangpricha V, Den Heijer M. Oestrogen and anti-androgen therapy for transgender women. Lancet Diabetes Endocrinol. 2017;5(4):291–300. https://doi.org/10.1016/S2213-8587(16)30319-9
Callen Lorde Community Health Center. Protocols for the provision of hormone therapy [homepage on the Internet]. New York, NY; 2018 [cited 2021 Aug 12]. Available from: https://callen-lorde.org/graphics/2018/04/Callen-Lorde-TGNC-Hormone-Therapy-Protocols.pdf
Irwig MS. Clinical dilemmas in the management of transgender men. Curr Opin Endocrinol Diabetes Obes. 2017;24(3):233–239. https://doi.org/10.1097/MED.0000000000000337
Moravek MB. Gender-affirming hormone therapy for transgender men. Clin Obstet Gynecol. 2018;61(4):687–704.
Turban JL, King D, Carswell JM, Keuroghlian AS. Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics. 2020;145(2):e20191725. https://doi.org/10.1542/peds.2019-1725
National Department of Health. Essential Drugs Programme. Hospital level (Adults) Standard Treatment Guidelines and Essential Medicines List. 5th ed. Pretoria: Department of Health of South Africa; 2019 [cited 2021 Aug 12]. Available at https://www.knowledgehub.org.za/elibrary/hospital-level-tertiary-and-quaternary-essential-medicines-list
Lai TC, McDougall R, Feldman D, Elder CV, Pang KC. Fertility counseling for transgender adolescents: A review. J Adolesc Health. 2020;66(6):658–665. https://doi.org/10.1016/j.jadohealth.2020.01.007
Nolan IT, Kuhner CJ, Dy GW. Demographic and temporal trends in transgender identities and gender confirming surgery. Transl Androl Urol. 2019;8(3):184.
Berli JU, Knudson G, Fraser L, et al. What surgeons need to know about gender confirmation surgery when providing care for transgender individuals: A review. JAMA Surg. 2017;152(4):394–400. https://doi.org/10.1001/jamasurg.2016.5549
Pittet B, Montandon D, Pittet D. Infection in breast implants. Lancet Infect Dis. 2005;5(2):94–106.
Ascha M, Massie JP, Ginsberg B, et al. Clarification regarding nonsurgical management of facial masculinization and feminization. Aesthet Surg J. 2019;39(4):NP95–NP96. https://doi.org/10.1093/asj/sjz008
Chen ML, Reyblat P, Poh MM, Chi AC. Overview of surgical techniques in gender-affirming genital surgery. Transl Androl Urol. 2019;8(3):191.
Wolter A, Diedrichson J, Scholz T, Arens-Landwehr A, Liebau J. Sexual reassignment surgery in female-to-male transsexuals: An algorithm for subcutaneous mastectomy. J Plastic Reconstr Aesthet Surg. 2015;68(2):184–191. https://doi.org/10.1016/j.bjps.2014.10.016
Maycock LB, Kennedy HP. Breast care in the transgender individual. J Midwifery Womens Health. 2014;59(1):74–81.
Ashley F. Surgical informed consent and recognizing a perioperative duty to disclose in transgender health care. McGill J. Law Health. 2019;13(1):73–116.
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
Luvuno Z, De Vries E. Challenges faced by trans and gender-diverse people in accessing public sector healthcare services. HIV Nurs Matters. 2020;11:10–12.
Transgender-affirming hospital policies [homepage on the Internet]. Lambda Legal; 2016 [cited 2021 Aug 12]. Available from: https://www.thehrcfoundation.org/professional-resources/transgender-affirming-hospital-policies
Ouspenski A. We fight more than we sleep: Shelter access by transgender individuals in Cape Town, South Africa [homepage on the Internet]. Cape Town: Gender DynamiX; 2014 [cited 2021 Aug 12]. Available from: https://www.genderdynamix.org.za/academic-research-and-publications
Hughto JM, Clark KA. Designing a transgender health training for correctional health care providers: A feasibility study. Prison J. 2019;99(3):329–342.
Sevelius J, Jenness V. Challenges and opportunities for gender-affirming healthcare for transgender women in prison. Int J Prison Health. 2017;13(1):32–40. https://doi.org/10.1108/IJPH-08-2016-0046
Routh D, Abess G, Makin D, Stohr MK, Hemmens C, Yoo J. Transgender inmates in prisons: A review of applicable statutes and policies. Int J Offender Ther Comp Criminol. 2017;61(6):645–666.
Maruri S. Hormone therapy for inmates: A metonym for transgender rights. Cornell J Law Public Policy. 2010;20(3):807–832.
Ozturk MB, Tatli A. Gender identity inclusion in the workplace: Broadening diversity management research and practice through the case of transgender employees in the UK. Int J Hum Resour Manag. 2016;27(8):781–802. https://doi.org/10.1080/09585192.2015.1042902
Nel JA. Editorial: South African psychology can and should provide leadership in advancing understanding of sexual and gender diversity on the African continent. London: Sage; 2014.
Payne M. Modern social work theory. 4th ed. Oxford: Oxford University Press; 2016.
South African School’s Act No. 84 of 1996. Republic of South Africa: Government Gazette; 1996.
Kim H-T. Vocal feminization for transgender women: Current strategies and patient perspectives. Int J Gen Med. 2020;13:43–52. https://doi.org/10.2147/IJGM.S205102
Oates J. Evidence-based practice in voice therapy for transgender/transsexual clients. San Diego, Oxford and Brisbane: Plural Publishing; 2006.
Ma EP, Yiu EM. Voice activity and participation profile. J Speech Lang Hear 2001. https://doi.org/10.1044/1092-4388(2001/040)
Hogikyan ND, Sethuraman G. Validation of an instrument to measure voice-related quality of life (V-RQOL). J Voice. 1999;13(4):557–569. https://doi.org/10.1016/S0892-1997(99)80010-1
Davies S, Papp VG, Antoni C. Voice and communication change for gender nonconforming individuals: Giving voice to the person inside. Int J Transgend. 2015;16(3):117–159. https://doi.org/10.1080/15532739.2015.1075931
Ridgeway CL, Correll SJ. Unpacking the gender system: A theoretical perspective on gender beliefs and social relations. Gend Soc. 2004;18(4):510–531. https://doi.org/10.1177/0891243204265269
Sutherland C, Roberts B, Gabriel N, Struwig J, Gordon S. Progressive prudes: A survey of attitudes towards homosexuality & gender non-conformity in South Africa. Pretoria: Department Service Delivery, Democracy and Governance, Human Science Research Council; 2016.
Iranti-org. Ending pathological practices against Trans and Intersex bodies in Africa [homepage on the Internet]. Johannesburg: Iranti-org; 2016 [cited 2021 Aug 12]. Available from: https://www.iranti.org.za/wp-content/uploads/2019/04/National-Intersex-Dialogue.pdf
Births and Deaths Registration Act No 51 of 1992. Republic of South Africa: Government Gazette; 1992.

Appendix 1: The role of health professionals in change of gender marker at Home Affairs: Act 49

South African legislation allows a transgender and gender diverse (TGD) person to change his or her gender marker, as well as his or her forename. Transgender and gender diverse people can apply to change their sex description in the birth register in terms of the Alteration of Sex Description and Sex Status Act 49 of 2003. Section 2(1) states:

In terms of section 2(2)(b), an application must include two reports by medical practitioners, the examples of which are provided below. The Act does not make gender reassignment surgery compulsory. Hormonal treatment is sufficient.⁹⁶

Application for forename change can be made as per Section 24 of the Births and Deaths Registration Act and does not require any letter.¹⁶¹

Appendix 2: Client information and consent form for feminising hormone therapy

Many TGD clients choose to seek gender-affirming care in the form of hormone therapy (HT). The decision to start on HT rests with you, the client, and not with your healthcare provider. The informed consent model of treatment provides you agency over this decision – it is the role of your doctor to support and guide you through this process safely and effectively.

You may have read up, or heard from other TGD people, about HT. Some of the information that you may have come across could potentially be out of date or inaccurate.

If you have any questions or concerns at any time, you should always feel free to raise these concerns with your healthcare provider.

Please remember that every client is unique and will respond differently to medication, and that one client’s treatment programme might differ substantially from another because of a variety of physiological and medical factors. Try not to compare the treatment you are receiving with that of anyone else – your journey is your own. If you have concerns about the efficacy of your treatment, make a point to discuss this with your provider at your next appointment.

Before starting on HT, there are a few points that are worth considering. This informed consent document will draw your attention to some of these points, as well as outline the expected effects, side effects and risks that are associated with HT to make sure that you have all the information you need to make the best decision about your body and your health.

The role of psychotherapy in transgender and gender diverse clients

Visiting a psychologist is not a requirement for initiating HT. Whilst previously some healthcare providers required a letter of diagnosis or referral, this is no longer necessary under international best practice.

Your doctor will ask you some questions to determine that you have a good support structure as you move forward. This is not because going on HT itself necessitates this but rather because for many clients of TGD experience, navigating the world is already difficult, and HT, although often resulting in many positive and beneficial changes, can also lead to some emotional lability. A solid support structure looks different for everyone; however, this may include friends, families, support groups, therapists or counsellors. Your doctor might suggest or offer you referrals to support groups and therapists, if you indicate that you might benefit from these.

The role of endocrinologists and other specialists

Hormone therapy does not need to be prescribed or monitored by an endocrinologist. Prescribing HT is well within the realm of a suitably skilled general practitioner (GP) or family physician. Not all GPs, nor all endocrinologists, have experience in managing gender-affirming HT, and the expertise of the clinician should be the guiding factor in determining who prescribes and monitors your HT.

You may benefit from visiting other allied healthcare professionals, such as speech therapists, or from medical specialists, such as plastic surgeons. Not every TGD client will necessarily want to pursue these options, and you should discuss your individual goals with your prescribing doctor.

Home affairs and gender marker

If you wish to update your gender marker on your birth certificate and ID document, the Department of Home Affairs requires two letters from healthcare professionals, which state that you have undergone medical or surgical gender reassignment. Either of these is sufficient; you do not need to have had surgery to update your gender marker. Unfortunately, at present, gender markers in South Africa are binary; thus, an ID document can reflect either female or male gender; there is no unspecified or non-binary marker. Your prescribing doctor can write one of your letters for the Department of Home Affairs and should be able to refer you to another healthcare provider to write the second letter.

If you wish to change your name, this process should be undertaken separate to updating your gender marker (either before or after). This does not require supporting letters from healthcare providers.

Potential challenges with legal documents: Some TGD persons have trouble with banking, registration as a student and writing examinations, registration of motor vehicles, and so on whilst they are waiting for their new documents. Some are accused of potential fraud because they do not look the same as the photograph in their identity document or their name may be different from the name on their qualification certificates. Changing one’s gender marker and names will take a while. You may want to consider how you will deal with it in the interim. You also may want to consider whether you need to change other documentation, for example your matric certificate.

Potential impact on emotions: The impact of hormones can be very diverse and individualised. Your mood may fluctuate. For example, some TGD women may experience being more moody or tearful at times.

Potential impact on relationships with family and significant others: Have you thought about the possible impact on your relationship with significant others? If you are in an intimate relationship, this may change when you start on hormones, and relationship roles may need to be renegotiated. A partner may grieve the loss of aspects of who you were and the way the relationship used to be. What possible impacts can it have on your family and how will you be able to deal with your family’s response? Have you considered the impact of the change of gender role in your family? Have you considered the impact of potential loss of fertility? Are there children that may be impacted and are the children prepared?

Potential change in sexual orientation: It is possible that your sexual orientation may remain constant or shift, either temporarily or permanently (e.g. shift in attraction or choice of sexual partners, widened spectrum of attraction and shift in sexual orientation identity).

Potential impact on safety: In some settings, the physical changes in hormones may have an impact on your safety, with people who do not fit into society’s expectations of male or female being at increased risk of violence.

Potential impact on employment: Some TGD persons experience discrimination in the workplace or struggle to obtain employment. This may be more difficult when your legal documents (e.g. identity document) and your appearance do not match.

Potential grief and loss: Some TGD people experience a sense of loss, for example a TGD woman may be treated differently by society when she is read as a female person. A TGD woman may also experience that she has become physically weaker.

Taste changes: Some TGD persons experience a change in their taste sensations, and their likes and dislikes of certain foods.

Body odour change: Some TGD persons experience a change in their body odour on hormone treatment.

Appetite and sleeping patterns: Often the TGD person will experience an increase of appetite, which, in turn, could lead to weight gain. Sleeping patterns may also be affected.

Feminising hormone therapy

Feminising HT is prescribed for assigned-male-at-birth clients who wish to feminise.

The backbone of feminising HT is oestrogen therapy. Anti-androgens (spironolactone, cyproterone acetate or bicalutamide) are sometimes used, although many clients can achieve testosterone suppression using oestrogen therapy alone.

The biggest concern with oestrogen therapy is the risk of clot formation, which can lead to deep venous thrombosis (DVT), or life-threatening pulmonary emboli. It is this risk that limits the amount of oestrogen we can safely give clients. Oral oestrogen (e.g. Estrofem or Premarin) carry a higher risk of these adverse events than parenteral (i.e. administered outside the digestive tract) oestrogen.

Your doctor will discuss with you the various options for HT that are available and help you to decide which form of treatment is best for you.

Costs of hormone therapy

It is important to remember that not only do different clients have different needs in accessing HT but also that prices for medication may vary between different pharmacies, and that these prices may fluctuate over time. The majority of clients can expect to spend approximately R300–R500 per month on HT. This does not include monitoring blood tests or doctor’s visits.

Changes that occur when using hormone therapy

The changes you will experience on HT often take some time to fully develop. Some of these changes are reversible, and will disappear should you discontinue HT. Others are irreversible and will persist even if you stop taking your hormones.

The timeline for these changes to begin is variable; however, most of them will only reach their maximum degree after 3–5 years on HT.

Reversible changes

Irreversible changes

Limitations of hormone therapy

It is important to understand that there are certain features that HT cannot alter, which include the following:

Important risks associated with hormone therapy

As with any medication, HT carries with it certain risks. Some of these risks can be mitigated or reduced by lifestyle factors, whilst others are independent risks that cannot be altered. It is important to be fully aware of the risks associated with HT before starting your treatment.

Blood clots are the most prominent risk factor associated with feminising HT. A blood clot can lead to DVT, pulmonary embolism (a blood clot in the lungs), heart attacks or strokes. These conditions may be severely debilitating or even fatal:

Elevated levels of prolactin can rarely occur in clients on feminising HT because of the development of a prolactinoma, a benign (non-cancerous) tumour of the pituitary gland, which may interfere with vision. These can require surgical management, depending on the nature of the lesion.

Some of the risks mentioned are modified by other factors. Notably, cardiovascular and clot risk are worse in clients who

Some clients will experience a reduction in their blood pressure and improvements in their cholesterol levels on HT. This is not a guarantee and is not a replacement for positive lifestyle changes.

Fertility

Although not all clients become infertile on HT, and some might regain fertility if they stop HT, many may become irreversibly infertile. Hormone therapy is not a replacement for effective and responsible contraceptive use.

All clients considering starting on HT should consider using a Cryobank to preserve genetic material, in case they wish to conceive genetically related children at a later stage. Even if this is not a priority for you at this stage in your life, please consider the possibility that your perspectives might change with time, and that it is ideal to store material before starting HT rather than trying to regain fertility once you are already on hormone treatment.

Monitoring and follow up

Your doctor will advise and guide you in monitoring your safety while you are on HT. Usually, this will involve regular check-ups and physical examinations, as well as certain blood tests.

At the outset, it is not uncommon for these evaluations to be performed monthly, whilst you are still achieving the correct hormonal balance for you. Later, once you are stable on treatment, these intervals might be extended to 6-monthly, or perhaps even annually. This schedule is different for every client.

If you decide to stop your HT, you should discuss this decision with your doctor. It can be dangerous to abruptly withdraw HT without adequate medical supervision.

More information

Please remember that you can discuss any questions or concerns with your doctor at any time.

Informed consent for feminising hormone treatment

I confirm that my doctor has told me about the effects of feminising hormone treatment,

I understand that as part of my treatment plan, I shall take my medication as prescribed and have check-ups, including blood tests as required.

My doctor has offered me adequate opportunity to ask any questions that I have regarding feminising hormone therapy.

I hereby agree that my doctor starts/continues treating me with feminising hormone therapy.

Appendix 3: Client information and consent form for masculinising hormone therapy

Many TGD clients choose to seek gender-affirming care in the form of HT. The decision to start on HT rests with you, the client, and not with your healthcare provider. The informed consent model of treatment provides you agency over this decision – it is the role of your doctor to support and guide you through this process safely and effectively.

You may have read up, or heard from other TGD individuals, about HT. Some of the information that you may have come across could potentially be out of date or inaccurate.

If you have any questions or concerns at any time, you should always feel free to raise these concerns with your healthcare provider.

Please remember that every client is unique and will respond differently to medication, and that one client’s treatment programme might differ substantially from another’s because of a variety of physiological and medical factors. Try not to compare the treatment you are receiving with that of anyone else – your journey is your own. If you have concerns about the efficacy of your treatment, make a point to discuss this with your provider at your next appointment.

The role of psychotherapy in transgender and gender diverse clients

Your doctor will ask you some questions to determine that you have a good support structure as you move forward. This is not because going on HT itself necessitates this, but rather because for many clients of TGD experience, navigating the world is already difficult, and HT, although often resulting in many positive and beneficial changes, can also lead to some emotional lability. A solid support structure looks different for everyone; however, this may include friends, families, support groups, therapists or counsellors. Your doctor might suggest or offer you referrals to support groups and therapists, if you indicate that you might benefit from these.

The role of endocrinologists and other specialists

Hormone therapy does not need to be prescribed or monitored by an endocrinologist. Prescribing HT is well within the realm of a suitably skilled GP or family physician. Not all GPs, nor all endocrinologists, have experience in managing gender-affirming HT, and the expertise of the clinician should be the guiding factor in determining who prescribes and monitors your HT.

You may benefit from seeing other allied health professionals, such as speech therapists, or from medical specialists such as plastic surgeons. Not every TGD client will necessarily want to pursue these options, and you should discuss your individual goals with your prescribing doctor.

Home affairs and gender marker

Unfortunately, at present, gender markers in South Africa are binary – thus, an ID document can reflect either female or male gender; there is no unspecified or non-binary marker.

Your prescribing doctor can write one of your letters for the Department of Home Affairs and should be able to refer you to another healthcare provider to write the second letter.

Potential challenges with legal documents: Some TGD persons have trouble with banking, registration as a student and writing examinations, registration of motor vehicles, and so on whilst they are waiting for their new documents. Some are accused of potential fraud because they do not look the same as the photograph in their identity document or their name may be different from the one on their qualification certificates. Changing one’s legal gender marker and names will take a while. You may want to consider how you will deal with it in the interim. You also may want to consider whether you need to change other documentation, for example your matric certificate.

Potential impact on emotions: The impact of testosterone can be very diverse and individualised. Your mood may fluctuate. For example, often a TGD man may struggle to cry, and their emotions may become less intense. Some also experience increased irritability.

Potential impact on relationships with family and significant others: Have you thought about the possible impact on your relationship with significant others? If you are in an intimate relationship, this may change when you start on hormones, and relationship roles may need to be re-negotiated. A partner may grieve the loss of aspects of who you were and the way the relationship used to be. What are the possible impacts it can have on your family and how will you be able to deal with your family’s response? Have you considered the impact of the change of gender role in your family? Have you considered the impact of potential loss of fertility? Are there children that may be impacted and are the children prepared?

Potential grief and loss: Some TGD persons experience a sense of loss. A TGD man may lose certain gender roles in the family.

Taste changes: Some TGD persons experience a change in their taste sensations, and their likes and dislikes of certain foods.

Body odour change: Some TGD persons experience a change in their body odour on hormone treatment.

Appetite and sleeping patterns: Often the TGD person will experience an increase of appetite. This could lead to weight gain. Sleeping patterns may also be affected.

Masculinising hormone therapy

Masculinising HT is prescribed for assigned-female-at-birth clients who wish to masculinise. The backbone of masculinising HT is testosterone therapy. No additional medications are necessary to suppress oestrogen, as testosterone is able to do this alone.

The biggest concern with testosterone therapy is the risk of liver and cardiovascular disease. Testosterone use can adversely affect the liver, which is an organ vital to detoxifying the blood, and metabolising medications and dietary nutrients. Changes in testosterone levels have also been found to increase low-density lipoprotein (commonly known as ‘bad’) cholesterol and decrease high-density lipoprotein (commonly known as ‘good’) cholesterol. These changes in the metabolic profile can increase a client’s risk of heart attacks or strokes to levels similar to those seen in cisgender men.

Your doctor will discuss with you the various options for HT that are available and help you to decide which form of treatment is best for you.

Additional medications

For clients who wish to achieve suppression of menstruation, but have not performed so on testosterone alone, progesterone may be added.

Some clients will use topical minoxidil in order to achieve fuller facial hair growth.

Costs of hormone therapy

It is important to remember that not only do different clients have different needs in accessing HT but also that prices for medication may vary between different pharmacies, and that these prices may fluctuate over time. The majority of clients can expect to spend between R200 and R600 per month on HT. This does not include monitoring blood tests or doctor’s visits.

Changes that occur when using hormone therapy

The changes you will experience on HT often take some time to fully develop. Some of these changes are reversible and will disappear should you discontinue HT. Others are irreversible and will persist even if you stop taking your hormones.

The timeline for these changes to begin is variable; however, most of them will only reach their maximum degree after 3–5 years on HT.

Reversible changes

Irreversible changes

Limitations of hormone therapy

It is important to understand that there are certain features that HT cannot alter, which include the following:

Important risks associated with hormone therapy

As with any medication, HT carries with it certain risks. Some of these risks can be mitigated or reduced by lifestyle factors, whilst others are independent risks that cannot be altered.

It is important to be fully aware of the risks associated with HT before making the decision to start your treatment:

All of the above can lead to or worsen cardiovascular disease, or lead to strokes. These conditions can be life threatening.

Liver disease

Psychiatric symptoms include mood disturbances, anxiety or psychosis, especially if there are pre-existing mental health conditions. If you have been diagnosed with a mental health condition and/or use psychiatric medication, you need to discuss the starting of HT with your doctor. The use of hormones can interact with various medications and may have an impact on your mental health conditions.

Some of the risks mentioned are modified by other factors. Notably, cardiovascular and clot risks are worse in clients who

Fertility

All clients considering starting on HT should consider using a Cryobank to preserve their genetic material, in case they wish to conceive genetically related children at a later stage. Even if this is not a priority for you at this stage in your life, please consider the possibility that your perspectives might change with time, and that it is ideal to store genetic material before starting with HT rather than trying to regain fertility once you are already on HT.

Monitoring and follow-up

Your doctor will advise and guide you in monitoring your safety whilst you are on HT. Usually, this will involve regular check-ups and physical examinations, as well as certain blood tests.

If you decide to stop your HT, you should discuss this decision with your doctor. It can be dangerous to abruptly withdraw HT without adequate medical supervision.

More information

Please remember that you can discuss any questions or concerns with your doctor at any time.

Informed consent for masculinising hormone treatment

I confirm that my doctor has told me about the effects of masculinising hormone treatment, including the more common or serious risks and side effects as mentioned above.

I understand that as part of my treatment plan, I shall take my medication as prescribed and have check-ups, including blood tests, as required.

My doctor has offered me adequate opportunity to ask any questions that I have regarding masculinising hormone therapy.

I hereby agree that my doctor starts/continues treating me with masculinising hormone therapy.

Guideline

Southern African HIV Clinicians’ Society gender-affirming healthcare guideline for South Africa

Contents

Executive summary

Scope and purpose

Audience

Methods

1. Introduction

2. Informed consent

2.1. The process

2.2. Hormone therapy and surgery

2.3. Children and adolescents

2.4. Intellectual and developmental disability

3. Primary care

3.1. The importance of the primary care provider

3.2. Comprehensive care

3.2.1. Violence

3.2.2. Mental health

3.2.3. Substance use

3.2.4. Fertility and contraception

3.2.5. Cancer

3.2.6. Sexual health

3.2.7. Sexually transmitted infections

3.2.8. HIV

3.2.9. Physical examination

4. Non-medical gender-affirming practices

4.1. Binding

4.2. Tucking

4.3. Padding and packing

5. Psychosocial care

5.1. The role of the mental healthcare provider

5.2. Children

5.3. Adolescents

5.4. Adults

5.5. The meso and macro context

6. Hormone therapy

6.1. Background

6.2. Indications

6.3. Feminising therapy

6.4. Masculinising therapy

6.5. Adolescents

6.6. Mature clients

7. Surgery

7.1. Preoperative considerations

7.2. Peri-surgical care

8. Institutions

8.1. Care facilities

8.2. Correctional facilities

8.3. Work facilities

8.4. Educational facilities

9. Voice and communication

10. Key terms

Acknowledgements

Competing interests

Authors’ contributions

Ethical consideration

Funding information

Data availability

Disclaimer

References

Appendix 1: The role of health professionals in change of gender marker at Home Affairs: Act 49

Appendix 2: Client information and consent form for feminising hormone therapy

The role of psychotherapy in transgender and gender diverse clients

The role of endocrinologists and other specialists

Home affairs and gender marker

Feminising hormone therapy

Costs of hormone therapy

Changes that occur when using hormone therapy

Reversible changes

Irreversible changes

Limitations of hormone therapy

Important risks associated with hormone therapy

Fertility

Monitoring and follow up

More information

Informed consent for feminising hormone treatment

Appendix 3: Client information and consent form for masculinising hormone therapy

The role of psychotherapy in transgender and gender diverse clients

The role of endocrinologists and other specialists

Home affairs and gender marker