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A publication of the Southern African HIV Clinicians Society
SAHCS
GUIDELINES
SOUTHERN AFRICAN HIV CLINICIANS SOCIETY
GENDER-AFFIRMING HEALTHCARE GUIDELINE FOR
SOUTH AFRICA - EXPANDED VERSION: OCTOBER 2021
2 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
SOUTHERN AFRICAN HIV CLINICIANS SOCIETY GENDER-AFFIRMING
HEALTHCARE GUIDELINE FOR SOUTH AFRICA - EXPANDED VERSION:
OCTOBER 2021
Two guideline documents have been developed. The condensed guideline provides a quick reference and summary of the main
aspects relating to gender-arming healthcare in South Africa. This second, expanded version provides further detail for those
requiring additional background information, resources and references.
Condensed guideline citation: Tomson A, McLachlan C, Wattrus C, et al. Southern African HIV Clinicians Society gender-arming
healthcare guideline for South Africa. South Afr J HIV Med. 2021;22(1):a1229.
https://doi.org/10.4102/sajhivmed.v22i1.1299
Guideline development committee: Anastacia Tomson,1,2* Chris/tine McLachlan,3,4,5,6 Camilla Wattrus,7 Kevin Adams,5,8 Ronald
Addinall,5,9,10 Rutendo Bothma,11 Lauren Jankelowitz,12 Elliott Kotze,13 Zamasomi Luvuno,14 Nkanyiso Madlala,4,5,6 Savuka Matyila,15
Anil Padavatan,15 Mershen Pillay,5,16,17 Mmamontsheng Dulcy Rakumakoe,5,18 Mathilde Tomson-Myburgh,2 W D François Venter,19
Elma de Vries5,20,21
1My Family GP, Cape Town, South Africa
2Shemah Koleinu, Cape Town, South Africa
3KwaZulu Natal Department of Health, Pietermaritzburg, South Africa
4Department of Psychology, College of Human Sciences, University of South Africa, Pretoria, South Africa
5Professional Association for Transgender Health (PATHSA), Cape Town, South Africa
6Psychological Society of Southern Africa (PsySSA), Johannesburg, South Africa
7Southern African HIV Clinicians Society (SAHCS), Cape Town, South Africa
8Department of Plastic Surgery, Faculty of Health Sciences, University of Cape Town, South Africa
9Department of Social Development, Faculty of Humanities, University of Cape Town, Cape Town, South Africa
10Southern African Sexual Health Association (SASHA), Cape Town, South Africa
11Wits Reproductive Health Institute (Wits RHI), Johannesburg, South Africa
12Southern African HIV Clinicians Society (SAHCS), Johannesburg, South Africa
13Psychologist, Independent Practice, Cape Town, South Africa
14School of Nursing and Public Health, Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
15Gender DynamiX, Cape Town, South Africa
16Department of Speech-Language Therapy, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
17Department of Speech-Language Therapy, Faculty of Health Sciences, Massey University, Auckland, New Zealand
18Quadcare, Johannesburg, South Africa
19Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
20Cape Town Metro Health Services, Cape Town, South Africa
21School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
Corresponding author: Anastacia Tomson (doc.tomson@gmail.com)
Contributors: The guideline development committee would like to acknowledge the contributors who strengthened the guideline
with valuable feedback 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 R. 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.
The committee also acknowledges and thanks the following legal advisors for their contribution: Mandi Mukarikwa and Charlene May
from the Women’s Legal Centre, and Karabo Ozah and Moyahabo Thoka from the Centre for Child Law.
Acknowledgment of funding: The Southern African HIV Clinicians Society (SAHCS) gratefully acknowledges the receipt of funding
from the Wits Reproductive Health and HIV Institute (Wits RHI) through the support of the American People through the U.S.
President’s Emergency Plan for AIDS Relief (PEPFAR) as implemented by the United States Agency for International Development
(USAID) for the development and publication of these expanded guidelines. The contents of the SAHCS GAHC guidelines do not
necessarily reect the views of USAID or the United States Government
Conict of interest: None. The donor did not participate in guideline development.
Suggested citation: Tomson A, McLachlan C, Wattrus C, et al.; for the Southern African HIV Clinicians Society. Southern African HIV
Clinicians Society gender-arming healthcare guideline for South Africa – expanded version. October 2021. Available at: https://
sahivsoc.org/Subheader/Index/sahcs-guidelines.
Disclaimer: To the fullest extent permitted by law, the Southern African HIV Clinicians Society (SAHCS) and the authors of this
document cannot be held liable for any aspect of healthcare administered with the aid of this information or any other use of this
information, including any use which is not in accordance with any guidelines or (mis-)use. Specic recommendations provided
here are intended only as a guide to clinical management, based on expert consensus and best current evidence at the date of
rst publication. Management decisions for patients should be made by their responsible clinicians, with due consideration for
individual circumstances and various contexts. The information contained in this document should not be considered a substitute
for such professional judgment. The most current version of this document should always be consulted.
License: This guideline is licensed under the Creative Commons CC BY-NC-ND 4.0 license. Licensee: Southern African
HIV Clinicians Society.
Endorsements:
This guideline is endorsed by:
Be True 2 Me, a trans-led organisation that provides a unied point of contact for
Transgender & Gender Diverse individuals, and those interacting with, working with,
educating, employing or caretaking Transgender & Gender Diverse people.
Centre for Sexualities, AIDS and Gender (CSA&G), University of Pretoria
Gender Dynamix (GDX), Africa-based public benet organisation focussing on
transgender and gender diverse communities.
Professional Association for Transgender Health South Africa (PATHSA), an
interdisciplinary health professional organisation working to promote the health,
wellbeing and self-actualisation of trans and gender diverse people.
Psychological Society of South Africa (PsySSA), the professional body
representing psychology professionals in South Africa.
Sexuality and Gender Division (SGD) of the Psychological Society of South Africa
(PsySSA), a division of PsySSA that promotes a psychological understanding of the
elds of sexuality and gender diversity, including queer identities and position.
Same Love Toti, a registered non-prot organisation that helps parents to
understand their LGBTI children, and supports LGBTI youth.
TransHope, an NGO bringing hope to the gender diverse community.
Triangle Project, a non-prot human rights organisation oering professional
services to ensure the full realisation of constitutional and human rights for lesbian,
gay, bisexual, transgender, queer and intersex (LGBTQI+) persons, their partners
and families
Wits Reproductive Health and HIV Institute (Wits RHI), a leading multi-
disciplinary research institute with a focus on sexual and reproductive health,
vaccines and infectious diseases, and other emerging health challenges. The Wits
RHI Key Populations Programme operates USAID-supported transgender healthcare
centres in four health districts in Gauteng, Eastern Cape and Western Cape.
Uthingo Network, previously The Gay & Lesbian Network, a registered non-prot
organisation that aims to create a non-discriminatory, supportive and accepting
society in which members of all communities are uplifted and developed, and
ensuring optimum commitment and services and programmes for the upliftment
and recognition of the lesbian, gay, bi-sexual, transgender and intersex (LGBTI)
communities.
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TABLE OF CONTENTS
List of abbreviations 7
Executive summary 8
Scope and purpose 8
Audience 8
Methods 8
CHAPTER 1: Introduction 10
1.1 Background 10
1.2 Values underpinning the guideline 10
1.2.1 Armation 10
1.2.2 Dignity 11
1.2.3 Equity 11
1.2.4 Inclusion 12
1.2.5 Informed consent 13
1.2.6 Healthcare provider’s ethics and principles 13
1.2.7 Ubuntu – participatory approach 14
1.2.8 Batho Pele 15
1.2.9 Trans giftedness 15
1.3 Key terms 16
1.4 Gender-arming healthcare 17
1.4.1 How to create an arming space – practical tips 18
CHAPTER 2: Informed consent 20
2.1 Background 20
2.2 Informed consent in children and adolescents 21
2.2.1 Broad legal principle for consent in children 21
2.2.2 Informed consent for psychosocial care for children younger than 12 years 21
2.2.3 Informed consent for psychosocial care for children older than 12 years 22
2.2.4 Informed consent for puberty suppression or hormone therapy in adolescents 23
2.2.5 Informed consent for surgery in adolescents 23
2.3 Informed consent in adults 24
2.3.1 Informed consent for psychosocial care for adults 24
2.3.2 Informed consent for hormone therapy for adults 24
2.3.3 Informed consent and psychosocial assessment for surgery for adults 25
2.4 Informed consent for adults with intellectual and developmental disabilities
and who have limited capacity to consent 24
2.4.1 Relevant legislation and frameworks 26
2.4.2 Person-centred planning 26
2.4.3 Communication 27
2.4.4 Informed consent in the context of intellectual and developmental disabilities 27
2.4.5 Consent, capacity and decision-making 28
CHAPTER 3: Primary care 29
3.1 Importance of the primary care provider 29
3.2 Comprehensive care 29
3.2.1 Violence 29
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3.2.2 Mental health 30
3.2.3 Screening for alcohol, tobacco and drug use 30
3.2.4 Fertility and contraception 30
3.2.5 Cancer 31
3.2.6 Sexual health 31
3.2.7 Sexually transmitted infections 33
3.2.8 HIV 34
3.3 Physical examination 35
CHAPTER 4: Non-medical gender-arming practices 36
4.1 Background 36
4.2 Binding 36
4.3 Tucking 37
4.4 Padding and packing 36
CHAPTER 5: Psychosocial care 38
5.1 Background and approach to psychosocial care 38
5.2 The role of the mental healthcare practitioner 38
5.3 Transgender and gender diverse children 40
5.3.1 Working with a TGD child 41
5.3.2 A TGD child and their family 42
5.3.3 A TGD child and their school 42
5.3.4 A TGD child and their community 43
5.3.5 A TGD child and broader society 43
5.4 Transgender and gender diverse adolescents 43
5.4.1 Working with a TGD adolescent 44
5.4.2 A TGD adolescent and their family 45
5.4.3 A TGD adolescent and their school or higher education institution 45
5.4.4 A TGD adolescent and their community 45
5.4.5 A TGD adolescent and broader society 46
5.5 Transgender and gender diverse adults 46
5.5.1 Working with a TGD adult 46
5.5.2 A TGD adult and their family 46
5.5.3 A TGD adult and intimate relationships 46
5.5.4 A TGD adult and their workplace 47
5.5.5 A TGD adult and their community 47
5.5.6 A TGD adult and broader society 47
5.6 Elderly transgender and gender diverse adults 47
5.7 Conclusion 48
CHAPTER 6: Hormone therapy 49
6.1 Background 49
6.2 Indications 49
6.3 Process of prescribing hormones 49
6.3.1 Holistic treatment 50
6.3.2 Baseline assessment 50
6.3.3 Clinical examination 50
6.3.4 Discussion of reproductive options 50
6.4 Feminising hormone therapy 52
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6.4.1 Risks and side eects of feminising treatment 52
6.5 Masculinising hormone therapy 55
6.5.1 Risks and side eects of masculinising treatment 55
6.6 Laboratory monitoring of hormone therapy 55
6.6.1 Managing laboratory abnormalities 57
6.7 A note on hormone therapy for non-binary clients 57
6.8 Adolescents 57
6.9 Mature TGD clients 58
CHAPTER 7: Surgery 59
7.1 Background 59
7.2 Initial consultation 60
7.2.1 Note on physical examination, particularly the genitalia 60
7.3 Transition pathway 60
7.3.1 Adolescents 60
7.4 Pre-operative considerations 60
7.5 Peri-surgical care 62
CHAPTER 8: Institutions 63
8.1 Where you stay 63
8.1.1 Care facilities 63
8.1.2 Correctional facilities 64
8.2 Where you work 65
8.2.1 Human resource support for TGD inclusion 65
8.2.2 Oce bathrooms 66
8.3 Where you learn 66
8.3.1 Schools 66
8.3.2 Higher education institutions 68
CHAPTER 9: Voice and communication 70
9.1 Background 70
9.2 Role of the speech-language therapist 70
9.3 General considerations for voice and communication 70
9.4 Voice and communication assessment 71
9.4.1 Personal prole 71
9.4.2 Assessment of voice and communication 71
9.5 Voice and communication interventions 73
REFERENCES 74
APPENDICES 88
APPENDIX A: Role of health professionals in gender marker change at the
Department of Home Aairs: Act No. 49 88
A1. Suggested letter in support of application to the Department of Home Aairs for
change in gender marker – medical doctor 91
A2. Suggested Letter in support of application to Department of Home Aairs for
change in gender marker – surgeon 92
A3. Suggested letter in support of application to Department of Home Aairs for
change in gender marker – clinical psychologist / counselling psychologist / educational
psychologist / clinical social worker 93
APPENDIX B: Client information and informed consent form for feminising hormone therapy 94
APPENDIX C: Client information and informed consent form for masculinising hormone therapy 99
APPENDIX D: Community resources 103
7 | Gender-arming guidelines – Expanded version - October 2021
ACE-I angiotensin-converting-enzyme inhibitor
AFAB assigned female at birth
ALT alanine transaminase
AMAB assigned male at birth
ARB angiotensin receptor blocker
ART antiretroviral therapy
BMD bone mineral density
Cr creatinine
CRPD United Nations Convention on the Rights of
People with Disabilities
CYP cytochrome P450
DSD dierences/diversity of sexual development
DSM-5 Diagnostic and Statistical Manual for Mental
Disorders Version 5
DTG dolutegravir
DVT deep venous thrombosis
EFV efavirenz
FBC full blood count
FFS facial feminisation surgery
FTC emtricitabine
GnRHa gonadotrophin-releasing hormone
agonist(s)
GAHC gender-arming healthcare
GBV gender-based violence
GP general practitioner
Hb haemoglobin
HBV hepatitis B virus
HCV hepatitis C virus
HEI higher education institution
HPV human papillomavirus
HSV herpes simplex virus
Ht haematocrit
HT hormone therapy
IC informed consent
ICD-11 International Classication of Diseases and
Related Health Problems Version 11
ICM informed consent model
ID identity document
IUD intrauterine device
IM intramuscular
LFT liver function test
LGBTQIA+ lesbian, gay, bisexual, transgender, queer/
questioning, intersex, asexual/agender,
developing language and the inclusion of
other diverse gender identities and sexual
orientations
LGBTQQIP2SAA
lesbian, gay, bisexual, transgender,
questioning, queer, intersex, pansexual,
two-spirit (2S), androgynous and asexual
MHC mental healthcare
MHCA Mental Health Care Act
MHP mental healthcare provider/practitioner
MoCA-LD Montreal Cognitive Assessment –
Learning Disabilities
MSM men who have sex with men
NG54 National Institute for Health and Care
Excellence Guidelines on Mental Health
Problems in People with Learning
Disabilities: Prevention, Assessment and
Management
NHI National Health Insurance
NIMART nurse-initiated management of
antiretroviral therapy
NVP nevirapine
PATHSA Professional Association for Transgender
Health South Africa
PEP post-exposure prophylaxis
POPIA Protection of Personal Information Act
PrEP pre-exposure prophylaxis
PSA prostate-specic antigen
PsySSA Psychological Society of South Africa
PTSD post-traumatic stress disorder
PWIDD person(s) with intellectual and
developmental disabilities
SASL South African Sign Language
SBIRT screening, brief intervention and referral
to treatment
SC subcutaneous
SFF speaking fundamental frequency
SHBG sex hormone binding globulin
SLT speech-language therapist
SoC-7 World Professional Association for
Transgender Health Standards of care for
the health of transsexual, transgender, and
gender-nonconforming people, version 7
SRHR sexual and reproductive health and rights
STI sexually transmitted infection
TDF tenofovir disoproxil fumarate
TGD transgender and gender diverse/diversity
TGM transgender man/men
TGW transgender woman/women
UEC urea, electrolytes and creatinine
ULN upper limit of normal
VTE venous thromboembolism
WHO World Health Organization
WPATH World Professional Association for
Transgender Health
ABBREVIATIONS
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EXECUTIVE SUMMARY
We support an arming approach to managing
the transgender and gender diverse (TGD) client,
centring on the individual’s agency, autonomy
and right to self-determination, as opposed
to practices that pathologise and stigmatise
TGD identity, imposing barriers to accessing
healthcare.
TGD persons 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 persons
continue to face marginalisation, prejudice
and threats to their safety. Challenges persist
– including homelessness, unemployment,
poor social support, bullying, harassment
and violence – indicating failures of policy
development and practice implementation, and
a disregard for the human rights of persons in
the TGD community.
This guideline has been developed primarily
with the intention of centring and amplifying
voices of TGD persons in order to facilitate
access to healthcare that is sensitive, skilled and
respectful. We recognise that there are signicant
gaps in the knowledge and skills of healthcare
providers, and 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 dignied gender-arming
healthcare (GAHC) is not only safe, but also
plays a signicant 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 persons have
historically endured being undermined,
condescended to and pitied by the healthcare
system and its providers. We arm a
commitment to upholding a strength-based
perspective that values and respects the
experiences of TGD clients and celebrates
individual identity rather than merely accepting
or tolerating it.
This guideline, which will undoubtedly require
ongoing revision, reection and renement
in consultation with TGD communities and
healthcare providers, represents a rst step
made in good faith towards creating a practical
tool founded in robust scientic evidence,
lodged within a human rights framework, and
is intended to facilitate access to skilled and
sensitive care that will yield tangible benet to
this unique and important group.
↑ Back to Table of Contents
9 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents ↑ Back to Table of Contents
SCOPE AND PURPOSE
• Provide evidence-informed best practice
recommendations to enable South African
healthcare providers, including psychosocial
and allied healthcare professionals, to oer
quality, arming services to TGD clients
• Provide a support to TGD clients when
accessing healthcare services
• Note: this publication is the expanded
version of the guideline; the condensed
guideline can be accessed here:
https://doi.org/10.4102/sajhivmed.
v22i1.1299
AUDIENCE
This includes all healthcare providers, particularly
those working in a primary care setting (public
or private) and/or who care for TGD clients.
METHODS
The guideline development committee
comprised 17 individuals, chaired by Dr
Anastacia Tomson and Rev Chris McLachlan. This
committee was inclusive, with representation
of GAHC 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 as
well as sprovider experience from within the
eld. The committee worked from a gender-
arming, 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] In order to ensure
applicability to the South African context,
focused eort 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 review. Guideline development
and publication was supported by the Southern
African HIV Clinicians Society (SAHCS), through
Dr Camilla Wattrus and Dr Lauren Jankelowitz.
The committee has used the term ‘client’ which,
for the purposes of this guideline, includes
service users, patients and participants.
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INTRODUCTION
1.1 Background
‘I don’t think we really know what freedom is in South
Africa. What will it take for me to have the freedom and
safety to stand up in public and say, “I am gender uid”?
I don’t just feel marginalised, I feel like there is no space
for me at all.’ - Anonymous TGD client, pers. comm.,
2020
South Africa is a country with a progressive
Constitution and Bill of Rights that provide for
dignity, equality and access to healthcare.[4] This is
echoed by the South African Health Professions
Act and associated general ethical rules for health
professionals;[5] the Social Service Professions Act,[6]
the Constitutions of the Professional Association for
Transgender Health in South Africa (PATHSA)[7]and
Psychological Society of South Africa (PSySSA)[8]; and
the Department of Health’s Batho Pele principles.[9]
Despite this, many transgender and gender diverse
(TGD) persons struggle to access gender-arming
healthcare (GAHC) in South Africa.
GAHC attends holistically to a TGD individual’s
mental, physical and social well-being and health
needs, while respecting their self-identied gender.
[10] Each individual has unique needs, and the gender-
arming process is rarely linear. This process may
include social and/or medical elements, or none at
all.[11] A client with a non-binary identity may have
unique and specic treatment goals.[12]
Transition is not necessarily medical. Persons who
do not or cannot access GAHC can still arm their
gender expression and transition socially.[13]
‘Because for me, my transitioning is more spiritual
than physical. I live as a woman every day. My nieces
and my nephews, they call me mom, and nding
peace within myself and being able to ght for them
to have a representation of what love looks like
makes me feel fullled. Your womanhood is within
you more than what is here on the physicality.’[13]
It is important to note that, as a healthcare provider,
withholding or delaying treatment is not a neutral
action. It can impact the client’s mental health and,
in adolescents, may have implications for 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.[14]
1.2 Values underpinning the guideline
The values underpinning this guideline are shown in
Box 1 and discussed below.
BOX 1: Values underpinning this guideline.
• Armation
• Dignity
• Equity
• Inclusion
• Informed consent (IC)
• Ethical principles in healthcare
• Ubuntu – the participatory approach
• Batho Pele – “People First”
• Trans giftedness
1.2.1 Armation
We arm and respect TGD persons and acknowledge
that the full spectrum of gender identities and
diversities is valid.[3]
Transgender and gender diversity (TGD) is an
‘expression of gender characteristics, including
identities that are not stereotypically associated
with one’s assigned sex at birth [that] is a common
and culturally diverse human phenomenon [that]
should not be judged as inherently pathological or
negative’.[15]
We understand that the concept of gender varies
in relation to political and sociocultural contexts,
personal and intergenerational trauma, migrant and
disability status, among others.[16] We avoid assuming
links between gender role, sexual orientation and
gender identity based on traditional, binaried, cis-
heteronormative understandings of femininity and
masculinity.[17,18]
CHAPTER 1
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In the past, TGD was dened as a mental illness,
but in 2018 the World Health Organization (WHO)
published the International Classication of
Diseases and Related Health Problems Version 11
(ICD-11), which removed transgender identity from
the chapter on mental health disorders and included
it in a new chapter on conditions related to sexual
health. This acknowledges the fact that, while TGD
persons may require gender-arming mental and
physical health interventions, gender diversity itself
is not a mental health disorder.[19] While gender
diversity is increasingly being understood and
accepted as a normal part of human diversity, there
is still a long way to go to address this legacy of
stigma.[18]
In the Diagnostic and Statistical Manual for Mental
Disorders Version 5 (DSM-5), the Gender Dysphoria
diagnosis is still used[20] to describe the distress
that TGD persons may experience, as their sex
assigned at birth is incongruent to their gender
identity and/or expression. The DSM-5 articulates
explicitly that ‘gender non-conformity is not in itself
a mental disorder’. Although this is a controversial
term, the DSM-5 is a document that originated in
the United States of America and the inclusion of
gender dysphoria was also about ensuring access
to healthcare in an American context of managed
healthcare.[21]
We support the notion of depathologisation of TGD
identities[7,22] and adopt an armative stance towards
gender diversity. As armative healthcare providers,
we acknowledge that some of the past practices often
pathologised gender diversity and that this caused
harm to TGD persons.[3] Gender diversity is natural
and a normal feature of the human experience.[2,3] As
GAHC providers, we strive to be ethical, accountable
and respectful towards the TGD persons with whom
we engage. Non-discrimination stands central in our
approach and support of all TGD clients.[3]
The discrimination, marginalisation and lack
of armation experienced by members of the
TGD community have a major impact on access
to economic and educational opportunities and
contribute to vulnerability to health risks.[23] Access
to GAHC can have a powerful impact on well-being
and quality of life of those seeking such care, beyond
the immediate psychological and physical benets.
1.2.2 Dignity
All persons have the right to dignity,[4] and this
should be respected and protected. We acknowledge
that persons whose gender identity and gender
expression fall outside of narrow societal norms are
subject to stigma, discrimination and even violence.
The dignity of TGD community members is often
undermined in interactions with institutions,
including the healthcare system.[13] TGD clients
frequently have negative experiences within the
healthcare system, including having their identities
repeatedly scrutinised and questioned, and being
treated with paternalism and condescension by
healthcare providers.[24] There are many reports of
public humiliation, negative value judgment, and use
of inappropriate names and pronouns, experienced
by TGD clients when attempting to access the
healthcare system.[25]
‘When I want to access health services and I go to the
nurses at the clinic, there is no one that will assist
me, and they will interrogate me instead to produce
an ID that matches my gender.’ – Anonymous TGD
client, pers. comm.,2018[13]
It is therefore essential that, in addition to striving to
provide clinically sound and competent healthcare
services to the TGD community, service providers
must do so with the overarching goal of ensuring
that a client’s dignity and right to identity and
expression are respected. Competent medical care
that does not uphold personal dignity fails to full
the fundamental requirement of protecting and
promoting the rights of all human beings.
1.2.3 Equity
We uphold the Yogyakarta principles that state
all persons are equal, should have equal access
to their basic human rights, and no-one should be
subjected to unfair discrimination.[26] The Yogyakarta
Principles plus 10 (YP+10) further stipulate the ‘right
to freedom from criminalisation and sanction on the
12 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
basis of sexual orientation, gender identity, gender
expression or sex characteristics’.[27]
While working towards equitable access to quality
medical care for all persons, it is important to
recognise that some persons are subject to
intersecting layers of discrimination; such as race,
socio-economic status, geographic area, age, health
disparities, transphobia and homophobia, sexism
and gender discrimination, and the oppression of
women.[2] It is the role of healthcare providers to
challenge all forms of stigma, abuse, inequality and
oppression directed at the TGD minority.[3]
We seek to uphold the principle of equity by
recognising the need to ensure access to medical
treatment to the most vulnerable and marginalised
sections of the community.
Alex Müller describes four aspects of care:[28]
• Availability: lack of public health facilities and
services, both for general and LGBTQIA+-specic
concerns
• Accessibility: healthcare providers’ refusal to
provide care to LGBTQIA+ clients
• Acceptability: articulation of moral judgment
and disapproval of LGBTQIA+ clients’ identity, and
forced subjection of clients to religious practices
• Quality: lack of knowledge about LGBTQIA+
identities and health needs, leading to poor-quality
care.
In the South African context, the stark reality is that
GAHC is only available at a few tertiary hospitals in
the state sector, at four clinics providing HIV care
and hormone therapy (HT), and from a small number
of private practitioners. Research has shown that
whether a client is able to access GAHC largely
depends on whether they are fortunate enough to
nd a healthcare provider who has knowledge of
GAHC and is sympathetic to the needs of TGD clients.
[29] The same research identied the urgent need for
national guidelines to ensure that GAHC services are
made available throughout the healthcare system.[29]
Historically, GAHC has been easier to access for
clients who already enjoy a higher degree of societal
privilege than others.[29] For example, wealthier
clients have easier access to GAHC in the private
sector than those who use public sector facilities;[29]
clients who identify within the gender binary
and express themselves in ways that conform to
traditional societal gender roles, enjoy better access
to services than non-binary persons; clients who
identify as heterosexual are seen as more valid than
their gay/lesbian/bisexual/asexual counterparts;[30]
geographical privilege, with access to GAHC
more readily available in certain provinces[31] and
educational-level privilege, for example a person
who is able to understand and read English, will be
able to access information more easily than a person
who only speaks an indigenous language.
‘Even with the health system, it contributes to the
barriers too, because you nd that people can’t aord
the medical aid. And most of our people go to the public
hospitals and clinics where the nurses only know about
gay and lesbian people. Then you come with a new
term and they don’t even know where to box you.’ –
Anonymous TGD client, 2019.[13]
Access to GAHC has been geographically restricted
in ways that prejudice clients in rural, remote and
under-resourced areas.[13] Due to South Africa’s
colonial and apartheid past, the divide between
those who have access to resources and those who
do not, continues to fall along racial lines.
Recognising and addressing these inequalities is an
essential part of providing equitable access to GAHC.
It is acknowledged that healthcare has a historical
complicity in oppressive systems, for example
gender hierarchies. As healthcare providers, we need
to create a space that contributes to social justice for
all, including gender and sexually diverse persons,
where we add to the well-being and mental health of
all.[2,32,33,34] The National Health Insurance (NHI) aims
to ensure equitable access to health services for all
persons, and this has to include the health needs of
TGD individuals.[35]
1.2.4 Inclusion
TGD persons should be included as equal partners in
making decisions about their bodies and healthcare,
as well as in broader decision-making regarding
laws, policies and guidelines that impact their access
to healthcare.
To address the history of gatekeeping, paternalism,
cis-heteronormativity and exclusion, we adopt
the principle of inclusion. Gatekeeping refers to a
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situation where a healthcare provider decides what
is in the best interests of the client, because the
client is viewed as being unable to make their own
choices. Gatekeeping (intentionally or unintendedly)
may take the form of healthcare providers refusing
to provide access to GAHC until a client proves
that they are ‘really transgender’ or ‘transgender
enough’. Some healthcare providers have insisted
that the client must openly express their gender
identity for a particular period of time (commonly
and problematically termed ‘living as’ their gender)
before beginning GAHC.[36,37,38]
Gatekeeping can also take the form of healthcare
providers guarding access to resources, and deciding
which clients are ‘worthy’ of medical care.
‘It’s a waiting list [to see a psychologist] of at least three
months. I was there at the clinic to do some sensitisation
and then she said “transgender is not something urgent.
It is just for beauty. We’ll start with those people who
have committed suicides” (…) and I said, “if I cannot
be a female, I will commit suicide”. And then they
said “no, transgender is not something that is urgent”’
PN (2018).[13]
1.2.5 Informed consent
Healthcare providers and clients are partners
in making choices about medical treatment: the
provider should inform the client of the risks and
benets and the client should make an informed
decision about their healthcare, based on the
information provided.[39] This approach respects
a client’s agency over their own body and is both
clinically safe and ethically sound. We uphold the
notion of self-determination.[7] This is discussed in
more detail in Chapter 2: Informed consent.
1.2.6 Healthcare provider’s ethics and principles
The healthcare provider is ethically obligated to
treat the TGD client with dignity and respect, and to
facilitate access to care (both general and gender-
arming) without gatekeeping or judgment.
The framework of medical ethics has four
fundamental concepts and provides a lens
through which scenarios can be determined to be
the most ethically sound course of action.[14] A
human rights-based approach, focusing on human
dignity and equality, which oers GAHC based
on informed consent (IC) is consistent with the
healthcare principles of autonomy, non-malecence,
benecence and justice.
• Autonomy: The principle of autonomy respects
a person’s right to self-determination. The client
is recognised as an independent person, capable
of making their own decisions regarding their own
bodies. It is clear that this principle is best respected
and upheld by an approach that empowers a
client with information and then allows that client
to make an informed choice about their care
and respects such a decision; i.e. an informed
consent model (ICM). In contrast, a gatekeeping
model deprives the client of the ability to make an
independent choice and fails to respect the client’s
autonomy.[14]
• Benecence: The principle of benecence deals
with ensuring that one’s practice oers benet
to the client. Numerous scientic studies have
validated the notion that access to GAHC provides
better outcomes for TGD individuals, and so this
principle is consistent with the ICM of care.
• Non-malecence: Non-malecence is the
principle of medical ethics that advocates that
one’s practice should not intentionally harm
clients. As the side eects of GAHC are well-known,
and it has been shown to be safe, giving clients
full information on the risks and benets of the
treatment and allowing them to make a choice
cannot be seen as causing harm. In fact, as noted
above, gatekeeping approaches that deny or delay
access to treatment have been shown to cause
harm, particularly in terms of mental health and
well-being.[14]
• Justice: Justice describes the principle of medical
ethics devoted to fairness and equity in the
allocation of healthcare resources. Gatekeeping
approaches to GAHC tend to unfairly favour
those who start with greater resources, or those
who t within societal models of gender and
gender expression. On the other hand, IC does
not privilege or disadvantage persons based on
identity, background or experience. By removing
the barriers created by gatekeeping approaches,
healthcare providers can contribute towards
building a more just and equitable healthcare
system.
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Although these ethics are central in healthcare, one
cannot ignore that an imbalance of power may exist
between the healthcare provider and the TGD client.
The medical model is often very paternalistic with
the provider being placed into the expert position.
The healthcare provider needs to be aware of and
challenge this power imbalance. Cultural humility
becomes important which calls the healthcare
provider to reect and self-evaluate the potential
power imbalance between the clinician and the TGD
client,[3] and to use the opportunity to practically
analyse what knowledge and service-related skills
that they may possess, and those which they may
need to develop, abrogate or accommodate.
Community psychologist Prilleltensky (2012)[40]
provides a denition of well-being that frames these
guidelines: ‘well-being is a positive state of aairs,
brought about by the simultaneous and balanced
satisfaction of diverse objective and subjective needs
of individuals, relationships, organisations, and
communities.’ Prilleltensky[40] emphasises that well-
being must be understood as being inuenced by the
wider context in which individuals are embedded.
This perspective challenges mainstream approaches
to wellness which tend to focus on the level of the
individual who is seen as responsible for their well-
being, while overlooking the inuence of multiple
and intersecting levels of inuence: the personal
level, the interpersonal level, the organisational level
and the community level. Importantly, these levels
of inuence are intersecting and dialectical, and
characterised by justice, which includes:
• Personal/intrapersonal justice: Personal
empowerment, control and responsibility for one’s
well-being
• Interpersonal justice: Treating others with dignity
and respect
• Organisational justice: Information about
existing resources, culture of health promotion,
equity and respect
• Community justice: Treated fairly by social
systems.
Prilleltensky[40] proposes that optimal conditions of
justice at all levels promote well-being.
Murray et al.[41] propose a number of values and
assumptions that underly an approach to health
and wellness and acknowledge that well-being is the
outcome of a complex set of intersecting levels of
inuence:
• Oppression and empowerment: Social structures
and processes can lead to internalised,
psychological experiences of disempowerment.
Self-determination, democratic participation, and
negotiating power across clinical decision-making
leads to empowerment.
• Social justice: Health requires participation in
social movements and social action in pursuit of
social justice.
• Caring, community and compassion: Health
is predicated on a sense of community, social
support and inclusion.
• Health promotion and prevention: A multi-level,
ecological, systems framework is needed to
analyse health problems and design interventions
and organisations that promote health and
prevent ill-health.
• Diversity: Creating the conditions of health
requires challenging cultural norms that are
disempowering, celebrating diversity, amplifying
the voices of marginalised persons, and being
sensitive to the unique context of individuals and
their unique identities.
1.2.7 Ubuntu – the participatory approach
Umuntu ngumuntu ngabantu – A person is a person
through other people. The African concept of Ubuntu
is central to South Africa’s democracy. It calls on us
to see the inherent humanity in all people and helps
us to understand human interdependence within
the indigenous context. All persons need to be seen,
recognised and armed as who they are, in order to
live fullling human lives.[42,43]
Incorporating a participatory approach in GAHC, the
TGD client’s support network, family, friends and
community, as well as a multidisciplinary team of
healthcare providers, become part of the journey of
the TGD person.[2]
1.2.8 Batho Pele - “People First”
The eight Batho Pele principles aim to enhance the
quality and accessibility of government services
15 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
by improving eciency and accountability.[43,44,45]
Although these principles stem from the South
African government for all public services, they
are applicable to private facilities and non-prot
organisations as well.
• Consultation: All stakeholders should be consulted
on the nature, quantity and quality of services to
be provided in order to determine and meet the
specic needs and expectations of the client.
• Service standards: Citizens should be informed
of the level and quality of public services they will
receive so they can understand the process and
are aware of what to expect.
• Access: All citizens should have equal access
to services to which they are entitled, including
decentralised oces, use of indigenous languages,
sign language and improved service delivery to
physically, socially and culturally disadvantaged
persons.
• Courtesy: Citizens should be treated with courtesy
and consideration, including utilising tools and
systems which are inclusive to positively aect
customer care.
• Information: Citizens should be given full, accurate
information about the public services to which
they are entitled, including information available
in various ocial languages, South African sign
language(s), Braille and, when necessary, via the
use of augmentative or alternative communication
(AAC) methods. Induction training should be
compulsory to all new employees.
• Openness and transparency: Citizens should be
informed of the administration of departments,
and the management should be open and
transparent to all sta members.
• Redress: Accessible and anonymous mechanisms
for recording public dissatisfaction must be
established and sta must be trained to handle
complaints fast and eciently.
• Value for money: Public services should be
provided economically and eciently to give
citizens the best possible value for money.
1.2.9 Trans giftedness
TGD persons are generally resilient, self-
aware, possess inner strength and have unique
perspectives and insights.[46] This enables them to
engage with the world of gender in new and diverse
ways.[47] We acknowledge this and utilise a strength-
based perspective rather than condescending to,
undermining or pitying TGD persons.
1.3 Key terms
Denitions of important key terms from within the
eld of GAHC were drawn from a variety of academic
sources but have been adapted through consultation
with members of the TGD community in South
Africa. Please note that the list of key terms provided
in Table 1 is not exhaustive, and that the usage of
terms and associated meanings may change over
time. It is important to allow TGD persons to self-
identify and not impose the use of terminology on
them. It is also useful to listen to the experiences
described by clients, rather than expecting them to
use specic terminology.
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TABLE 1: Key terms.
Term Explanation
Cisgender Abbreviated as ‘cis’, describes a person whose gender identity and
expression matches their sex assigned at birth.[3]
Gender ‘An institutionalised system of social practices for constituting people as
two signicantly dierent categories, men and women; and organising
social relations of inequality on the basis of that dierence.’[48] Gender
is based on social norms and expectations. In many cultures, people
are divided into a gender binary of either men or women, but there are
also cultures that recognise other genders, sometimes as a third gender
category, or as a range of non-binary identities, for example genderqueer,
gender uid, bigender or agender. Most societies have a history of
systemic gender inequality, with men occupying a privileged position and
women being subjected to socioeconomic disadvantage, discrimination
and violence. In addition, in South Africa, colonisation has meant that the
binary Western perspective has been entrenched within our society.
Gender dysphoria The psychological and/or physical distress caused by the incongruence
between sex assigned at birth and gender identity. Not all TGD persons
experience gender dysphoria, but it can be debilitating for some. Although
gender dysphoria is a medical diagnostic classication in the DSM-5,[20] TGD
persons’ experiences of it are diverse and may aect their lives in various
ways.
Gender expression Aspects of a person’s physical appearance and behaviour, dened
culturally or socially to be either masculine or feminine. Every society has
its own normative assumptions and prescriptions about how women and
men should feel, dress, act, and work. Gender expression can also be uid
or non-conforming.[49]
Gender identity Dened by the Yogyakarta Principles (South Africa is a signatory to these
Principles), as ‘each person’s deeply felt internal and individual experience
of gender, which may or may not correspond with the sex assigned at
birth, including the personal sense of the body (which may involve, if freely
chosen, modication of bodily appearance or function by medical, surgical
or other means) and other expressions of gender, including dress, speech
and mannerisms’.[27]
Cis-heteronormativity Refers to the hierarchical system of power, prejudice and discrimination in
which cisgender and heterosexual individuals are privileged above sexual
and gender diverse (or perceived sexual and gender diverse) persons.
Intersex Refers to persons born with sex characteristics, such as chromosomes,
gonads or genitals that do not t typical binary notions of male or female
bodies. Intersex is an umbrella term used to describe a wide range of
natural bodily variations.[22] Some persons with intersex traits self-identify
as intersex, and some do not. Some prefer the term dierences of sex
development or diversity of sex development (DSD). The medical
term ‘disorder of sex development’ is often considered derogatory by
intersex persons as dierence or diversity should not automatically be
pathologised.
LGBTQIA+ An umbrella term for communities who, for dierent reasons, have a
shared experience of marginalisation and discrimination in society, and
who have shared goals of improving access to human rights and basic
freedoms. L stands for lesbian, G for gay, B for bisexual, T for transgender,
Q for queer or questioning, I for intersex, A for asexual or agender, and +
indicating developing language and the inclusion of other diverse gender
identities and sexual orientations.
Misgendering Intentionally or unintentionally using an inaccurate pronoun or
description in a way that undermines a person’s gender identity. Similarly,
deadnaming (necronym) refers to using a TGD person’s previous given
name, despite them having changed their name, or asked to be addressed
by a name that reects their gender identity.
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Non-binary A range of gender identities that do not fall into the traditional binary
categories of male or female. It is important to recognise that this
gender binary does not describe the identity of many people. Persons
with non-binary gender identities may identify as gender uid, gender
diverse, agender, genderqueer, gender non-conforming, transmasculine,
transfeminine or various other non-binary identities.
Sex A complex interplay of multiple physical characteristics (including
hormones, internal reproductive organs, gonadal tissue, genitalia and
chromosomes) that cannot be categorised into a binary of male or female.
When a child is born, they are usually assigned as either female – assigned
female at birth (AFAB) – or male – assigned male at birth (AMAB) – based
solely on the observed external genitalia at birth. This does not account for
intersex individuals, or for DSD, which is problematic.
Sexual orientation Describes who one is intimately attracted to, and with whom one has
emotional and/or sexual relationships and the sexuality with which one
may identify. Sexual orientation is not the same as gender identity.
Gender identity refers to a person’s experience of their own gender, and
sexual orientation refers to their attraction to others. A person’s gender
identity does not in any way predict their sexual orientation.
Transgender A term that describes a person who does not identify (wholly or partially)
with their sex assigned at birth. A transgender woman (TGW) is someone
who was AMAB but who identies as a woman. The previous term MTF
(male-to-female) is no longer considered widely acceptable or accurate. A
transgender man (TGM) is someone who was AFAB but who identies as
a man. The previous term FTM (female-to-male) is no longer considered
widely acceptable or accurate.
Transphobia An irrational and systemic hostility towards persons who are transgender,
gender diverse, or who otherwise do not fall into traditional gender
categories and norms.
AFAB, assigned female at birth; AMAB, assigned male at birth; DSD, diversity of sex development; DSM-5, Diagnostic and Statistical Manual Version 5;
TGD, transgender and gender diverse.
1.4 Gender-arming healthcare
In recent years, GAHC has moved beyond the
narrow and medicalised approach of diagnosing
and treating gender dysphoria, and instead, the
World Professional Association for Transgender
Health (WPATH) Standards of Care for the Health
of Transsexual, Transgender, and Gender-
Nonconforming People, Version 7 (SoC-7) focus
on providing TGD clients with ‘safe and eective
pathways to achieving lasting personal comfort with
their gendered selves, in order to maximize their
overall health, psychological well-being, and self-
fullment’.[18]
GAHC is safe and eective, and the risks and
benets of the various treatment options are well
understood.[18]
Components of GAHC are summarised in Table 2.
Because of the very individual needs of TGD
persons, the relationship and communication with
their healthcare providers is extremely important.
Providing a safe, welcoming and culturally
appropriate healthcare environment is essential
to ensure that a TGD client not only seeks care but
returns for follow-up.[51] An armative approach is
part of our ethical response to providing healthcare,
both in the public and private healthcare setting.[1]
Through armation and building rapport, the TGD
client will be free to disclose their gender identity.[2,52]
18 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
TABLE 2: Gender-arming healthcare components.[50]
Drug Action required
Primary and preventive care • General healthcare that is arming
• Care following violence
• Mental health screening and support
• Screening for substance use
• Fertility and contraception
• Cancer screening (cervical, breast and prostate)
• Sexual health
• STI screening
• HIV prevention and care
Psychosocial care • Counselling and psychotherapy to support the client in making
choices, improving resilience, dealing with trauma and navigating the
psychosocial aspects of transition; and provide a safe space for clients to
explore and develop their own dynamic gender identity/expression
Medical therapy • HT for masculinisation
• HT for feminisation
• Puberty blockers for adolescents
• Fertility preservation through gamete storage
Gender-arming surgery • Masculinising: mastectomy with chest reconstruction, phalloplasty or
metoidioplasty
• Feminising: breast augmentation, facial feminisation, orchidectomy,
vaginoplasty
Voice and communication therapy • Voice and communication interventions, both verbal and non-verbal
aspects
Hair removal • Electrolysis and/or laser treatment
Advice on the safe use of non-
medical gender-arming practices
• Binding, tucking, padding and packing
Peer support groups • Source of information, emotional support and empowerment
Structural interventions • Ensuring an arming space – see practical tips below and
Chapter 8: Institutions
HIV, human immunodeciency virus; HT, hormone therapy; STI, sexually transmitted infection.
1.4.1 How to create an arming space –
practical tips
1.4.1.1 Ensure sta are capacitated to provide
gender-arming healthcare[36]
• Provide sensitisation training for all sta, including
security, reception and administrative sta
• Provide GAHC training for clinical sta to ensure
that they are competent to provide services to
TGD clients.
1.4.1.2 Create a welcoming and supporting
physical environment[53]
• Provide gender-neutral toilet facilities (discussed
in more detail in Chapter 8: Institutions)
• Ensure signage is gender neutral.
1.4.1.3 Administrative processes[53]
• Recognise that TGD clients may have an identity
document (ID) that does not match their gender
expression.
• Ensure registration records and intake forms
reect the client’s name-in-use, legal name and
surname (if relevant, and in consultation with the
client), pronouns and gender.
• Ensure data systems that allow information on
TGD identities to be captured. Electronic data
systems that assign gender according to national
ID documents prove quite problematic for TGD
and have been implicated in healthcare avoidance
among TGD.
• Practice discretion with billing information in
terms of dierentiating between the client’s legal
name and name-in-use; and consult with the client
directly to avoid any breaches of condentiality.
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• Ensure the client’s gender identity and treatment
information are kept condential and protected
under the Protection of Personal Information Act
(Act No. 4 of 2013)(POPIA).[54]
1.4.1.4 Clinical encounters
• Routinely ask clients which name and pronouns
they use (see below)
• Use sensitive language when taking a sexual
history – see Table 3 in Chapter 3: Primary care[55]
• Ensure sensitivity during physical examination –
see Box 2 in Chapter 3: Primary care
1.4.1.5 Other supportive services
• Produce educational materials that include
the needs and experiences of TGD clients (see
APPENDIX D: Community resources)
‘Our educational materials that we nd at the hospitals
and at the clinics, they are only talking about (cisgender)
male-female relations. So, our educational material,
they need to be inclusive (…) If they are inclusive, they
will be able to reach other people’ – Anonymous TGD
client, 2018.[13]
1.4.1.6 Language use
Language is an important tool for creating an
arming environment.[55] The following simple steps
can go a long way towards creating trust and building
a positive relationship:
• Avoid assumptions and ask clients to provide their
names and pronouns (e.g. he/they/she).
• If a client’s name-in-use is dierent to the legal
name on their ID, then only use the legal name
where there is a legal requirement to do so.
• Allow clients to dene their own identities and
expression, and be aware that some non-binary
identities may not t in to existing categories.[56]
• Ask open-ended questions.
• Be aware that in South Africa, gender identity
and expression and sexual orientation are often
conated, and it may therefore be useful to listen
to the experience clients describe, rather than
focus on the terminology used.
• If you accidentally get someone’s name or
pronouns wrong, simply apologise and move
on, but never insist on using a name or pronoun
against a client’s wishes.
• Limit language as a barrier by ensuring that there
is sta competency in more than one of South
Africa’s eleven ocial languages and, if required,
basic South African Sign Language (SASL). South
Africa has eleven ocial languages, with SASL
additionally recognised as an ocial home
language in the education system, but English is
the dominant language in healthcare settings.
This can create a barrier when accessing GAHC.
Clients may only be able to describe their personal
gender identity and/or expression in a language
that is comfortable to them. When a TGD client
is expected to give IC when accessing GAHC, the
healthcare provider needs to ensure that the client
understands what they are consenting to (see
Chapter 2: Informed consent).
• It is important that we need to strive to make the
IC process available in all eleven ocial languages,
as well as basic SASL.
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INFORMED CONSENT
CHAPTER 2
2.1 Background
Informed consent (IC) in GAHC is complex and
nuanced.[57,58] The IC process should empower
the individual, by upholding their autonomy
and maintaining their integrity.[14] The client and
healthcare provider should be collaborative partners
in decision-making.[59,60] It is the responsibility of the
healthcare provider to inform the client of the risks
and benets of the various treatment options with
the aim of enabling the client to make an informed
decision about their own healthcare.[61] IC should be
seen as a continuous process, rather than a singular
event, and the discussion of IC with the client should
be repeated as necessary during follow up.[62]
Documentation of IC is important. Examples of IC
forms for HT can be found in Appendices B and C.
The autonomy of the TGD client must be respected
and upheld at all times.[62] Furthermore, guidelines
should facilitate access to care. Access to care must
be conducted in a responsible and safe manner, with
the best interests of the TGD person uppermost.[62]
Health providers have an ethical duty to prevent
harm (non-malecence).[14] In the context of GAHC,
such harm can include a health providers taking
advantage of power relationships and gatekeeping
access to care, as well as not disclosing the
psychosocial and physical risks of treatment, and the
risk of regret.[57]
Given recent legal challenges to GAHC such as Bell
vs. Tavistock[63] – to which WPATH,[64] the Professional
Association for Transgender Health South Africa
(PATHSA)[65] and Psychological Society of South Africa
(PsySSA)[66] objected – it is important to outline what
would be best practice in the South African setting. It
should also be noted that the Bell vs. Tavistock ruling
was subsequently overturned by the UK Appeal
Court on the 17th September 2021.
Furthermore, it needs to be acknowledged that even
in the most supportive and arming environment,
there is often an unequal power relationship
between the client and the healthcare provider.[67]
This, therefore, begs the question: is it ever possible
to give full and empowered IC in a space of duress,
anxiety, ill health, unequal power relations, fear
of displeasing a healthcare provider, or missing
treatment?[68] As healthcare providers we need to
be aware how this unequal power relationship can
have a negative and distressing impact on the TGD
client. A TGD person’s right to make choices about
their own body are often impacted by this dynamic
[69] and, as healthcare providers, we need to respect
body autonomy without external coercion.[68]
Communication is a key part of this partnership: the
healthcare provider needs to be able to give evidence-
based information in an appropriate language that
the client can understand, and the client needs
to be able to give the healthcare provider all the
necessary information about their health status.
Creating a relationship of trust is important.[60] If a
client feels that their rights will be respected, then
they are more likely to disclose personal information
to the healthcare provider, which in turn enables the
provider to give them appropriate advice. At times,
the TGD client has more knowledge regarding GAHC
than the clinician.[70] A healthcare provider who
upholds the paternalistic medical model may nd
this challenging.
IC is a critical factor in GAHC but is fraught with
historical trauma and distrust, due to its abuse,
especially in the form of gatekeeping,[14,71] while also
being an essential factor in ensuring the actualising
of ethical, evidence-based practice, holistic
comprehensive support, care and allyship, with the
best interest and well-being of the TGD client at the
centre.
Based on the relevant literature and practice-based
expert experience, IC intersects with factors such as:
age of consent laws, duty to disclose ethics, rules
governing condentiality, existing standards of care
guidelines for professional practice generally and
specic to GAHC, professional ethical codes, and
the various models of IC that are found in practice.
[57,58] All these factors need to be considered and
guidelines formulated that will ensure a client-
centred model of GAHC support with a participatory
approach, respecting the right to self-determination
and autonomy of the client.[65]
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2.2 Informed consent in children and
adolescents
2.2.1 Broad legal principles for consent in children
Based on the legal opinion obtained from the South
African Women’s Legal Centre and the Centre for
Child Law,[72] guidance has been sought from the
Constitution of the Republic of South Africa (No. 108
of 1996)[4] and the Children’s Act (No. 38 of 2005,
Section 129(2))[73] as follows: ‘A child may consent to
medical treatment if over 12 years and the child is
of sucient maturity and has the mental capacity
to understand the benets, risks, social and other
implications of the treatment.’[73]
The term ‘medical treatment’ is understood to be
a manifestation of the right to health as provided
for in Section 27 of the Constitution[4] and includes
access to psychosocial and mental health services.[74]
Therefore, in South Africa, a child who is over 12
years of age, and meets these stipulated criteria,
may independently give IC to both psychosocial
and medical assessment/s and intervention for
GAHC without legally requiring the support or
consent of their parents/legal guardians. All children
aged 12 years and younger legally require the
consent of their parents/legal guardians. In the
context of consent for surgical treatment in a child
over 12 years, the child must be assisted by their
parents/legal guardians (Children’s Act, Section
129(3)).[73]
Section 129(10) of the Children’s Act[73] indicates
that the parents/legal guardians of a child that is
younger than 12 years, or a child over that age but
of insucient maturity or unable to understand
the benets, risks and social implications of the
treatment, may not withhold consent for medical or
surgical treatment, based on their subjective beliefs.
The best interest of the child is the guiding principle,
as stated in Section 28(2) of the Constitution: ‘a
child’s best interests are of paramount importance
in every matter concerning the child’.[4]
2.2.2 Informed consent for psychosocial care for
children younger than 12 years
Since a child younger than 12 years of age cannot
give consent to engage in psychosocial/mental
health evaluation, support and counselling,[73] the
mental healthcare provider (MHP) must engage the
parents/legal guardians in obtaining consent for
both the TGD child and the parents/legal guardians
to participate collaboratively in evaluation, support
and counselling. This is also the ideal considering
that the evidence shows that the best well-being
outcome is achieved when family support is obtained
in GAHC.[17,18,75]
In most prepubescent children presenting with
indicators that they may be TGD, it is the parents/
legal guardians that request a psychosocial/mental
health evaluation, support and counselling. Here,
the MHP, after conrming consent, can move to
assessment. The duty to disclose and the MHP’s
ethical code should inform the process of obtaining
IC. Consent involves explaining what the process of
evaluation involves with the parents/legal guardians,
other relevant and involved family members and with
the child. Addressing the limitations of condentiality
with the child and the parents/legal guardians is
very important at this stage. It is critical at this point
that the MHP also assures the child that their role
is to support and arm them and their family, and
to assist them to be their authentic self.[17,18,75] Once
IC has been obtained and the evaluation process is
completed, it is essential to explain to the child (in
an age-appropriate way) and to the parents/legal
guardians, the ndings of the evaluation, followed
by disclosure of the recommended intervention,
such as a social transition. All the factors involved in
a social transition process should be explained and
discussed, including the benets and risks. It should
also be included that, should the child at any point
express a change of mind and no longer wish to
continue with the social transition, this too would be
supported. Once assent from the child and IC from
the parents/legal guardians is obtained, then the
social transition process can begin.[76]
A situation may arise where a source other than the
parents/legal guardians refers a child to an MHP and
attempts to engage the parents/legal guardians are
unsuccessful. When there is reason to believe that
the parents/legal guardians are not acting in the
child’s best interest and the child is believed to be
at risk of harm, the case must be referred to the
appropriate statutory authorities empowered to
investigate such a case. If need be, a court order may
be obtained to allow the child to access the GAHC
they need.[73] The MHP with expertise in GAHC for
children needs to serve as a consultant and possible
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witness to support such proceedings. This process
may also need to be followed if the parents disagree
about GAHC for their child. This situation should
be avoided at all costs, and all attempts to get the
parents/legal guardians to participate in the child’s
best interests should be exhausted, but not at the
risk of undue harm to the child.[73]
2.2.3 Informed consent for psychosocial care for
children older than 12 years
IC for TGD children older than 12 years is more
complex, as GAHC for these children potentially
involves elements of psychosocial/mental health
evaluation, support and counselling, as well
as medical intervention in the form of puberty
suppression and possible hormone therapy (HT) for
older adolescents.[17,18,75]
Some older TGD children may have been assessed
earlier in childhood and already undergone social
transition by the time they reach Tanner Stage 2 of
puberty.[18,64] In most of these cases, parents/legal
guardians are already working together with the MHP
when this next stage in the young person’s gender-
arming journey arrives. At this stage, it is the role
of both the MHP and the medical professional to
engage the TGD adolescent collaboratively in the
process of full disclosure with regards to the option
of puberty suppression, and later introduction
of gender-arming HT.[17,18,75] This requires that,
between the MHP and the medical professional, all of
the short- and long-term benets and risks of puberty
suppression and gender-arming HT are discussed
with both the adolescent and their parents/legal
guardians. All aspects of emotional, psychological,
social, physical and reproductive factors must be
addressed.[18,58] The discussion should also address
the possibility that, should the adolescent at any
time come to a changing or dierent awareness of
their experience of their gender identity, this too
is valid and the adolescent should feel free and
safe to express this and inform their parents/legal
guardians and supporting healthcare professionals.
This is so that the needed adjustments and changes
to their transition process can be made, including the
possibility of a diversion in their transition process. It
is important to ensure that the adolescent and their
caregivers fully understand which changes, resulting
from puberty suppression and gender-arming
HT, are reversible and which are irreversible, and
at which point in treatment the irreversible changes
will be in eect.[17,75] In addition, the irreversible
eects of endogenous hormones (if no treatment is
provided) should also be explained.
As a consequence of minority stress (see
Chapter 5: Psychosocial care) some adolescents
may be facing challenges navigating environments
that are prejudiced, discriminatory and ignorant
about gender identity and gender diversity. There
is also the possibility that some adolescents may
be facing additional life stressors and traumas or
have a genetic predisposition to, and/or may be
dealing with a number of possible mental health
conditions such as anxiety, depression, gender
dysphoria, body dysmorphia, adjustment disorders,
substance abuse, onset of bipolar mood disorder or
schizophrenia.[17,18,75] Evidence indicates that both
autism spectrum disorder (ASD) and autistic traits
are more common in TGD youth than in cisgender
youth.[77,78] The MHP, therefore, also needs to
address how the management of these conditions
may impact the GAHC process for the adolescent,
as part of the IC process.[18] It is critical that the
MHP makes it clear that having these mental health
concerns is not a feature of being TGD, nor are they
an exclusionary factor in accessing GAHC support.
It needs to be made clear that any adjustments to
the GAHC process as a consequence of also needing
to address a mental health diculty are done with
the best interests of the adolescent in mind and in
collaboration with them, along with the expressed
intention of ensuring the best possible outcome for
their overall well-being.[17,18,75]
There are also cases during adolescence, most
often around the time of the onset of puberty, that
gender incongruence and gender dysphoria may be
expressed and/or experienced for the rst time. In
many cases, parents are receptive and supportive of
their adolescent, and together with them will reach
out to healthcare providers for support. All of the
principles and factors already described in relation
to age of consent and IC apply in these cases as
well. A challenge often experienced here is the time
pressure felt and expressed by the adolescent to
engage as quickly as possible in social transition,
as well as in elements of medical transition. They
may request support with puberty suppression
and gender-arming HT (depending on their age
and Tanner stage of puberty), to halt or alter the
development of secondary sex characteristics of
their sex assigned at birth. At the same time, parents/
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legal guardians often feel overwhelmed, anxious
and concerned about the implications of GAHC
interventions. The MHP and medical professionals
need to work collaboratively with each other, the
adolescent client and their parents/legal guardians,
appreciating these pressures while ensuring that
due diligence regarding IC, as described earlier, with
the best interests and integrity of the adolescent as
the central principle.[17,18,75]
A situation may arise where an adolescent requests
assessment and intervention or a referral to an MHP
is received from the school, or any other source
other than the parents/legal guardians, and where
attempts to engage the parents/legal guardians are
unsuccessful. Another situation may arise where the
parents of the TGD adolescent disagree about GAHC
for their child. If there is reason to believe that the
parents/legal guardians are not acting in the best
interest of the adolescent, as above with younger
children, appropriate referral should take place.[76]
2.2.4 Informed consent for puberty suppression or
hormone therapy in adolescents
International evidence-based research and expert
authorities in GAHC for adolescents recommend
that pubertal suppression should be oered to
adolescents who are experiencing persistent gender
incongruence and who wish to alter the development
of unwanted secondary sex characteristics that occur
in puberty from Tanner Stage 2 onwards.[17,18,75,79,80] In
South Africa, an adolescent aged 12 years and older,
deemed competent and of sucient capacity, can
give IC to this treatment.[72] This IC principle would
also apply in cases where the introduction of gender-
arming HT in later adolescence is considered
appropriate and necessary for the adolescent. IC is
a continuous process, rather than a singular event.
[62] Clinicians may observe that adolescents have
evolving capacity over time as they mature.
Obtaining IC from the adolescent should ideally
occur:
i. in the collaborative, supportive context of a
multidisciplinary team with noted expertise in
assessing and intervening in adolescent physical,
psychological and social development.[79]
ii. with an appreciation of the inuence of family
dynamics, as far as possible with the support
and involvement of the parents/legal guardians.
Better family support for TGD youth is associated
with better mental health outcomes.[81,82] The
lack of parental/legal guardian support does not,
however, preclude access to treatment.[17]
iii. with emphasis that the adolescent needs
to understand all risks and benets of
the treatments and have considered
the reproductive health implications
and options (discussed in more detail in
Chapter 6: Hormone therapy).[17,18,75,79,80]
More caution needs to be taken when deciding
on medical treatments in the context of a TGD
adolescent with ASD. As noted by Strang[83] ‘it is often
harder for an adolescent with ASD to comprehend
the long-term risks and implications of gender-
related medical interventions, consenting for
treatment may be more complex in this population
… it is important for the clinician to present the
benets and risks in a concrete manner, appropriate
for the young person’s cognitive and communication
abilities’. TGD adolescents with ASD often have
unrealistic expectations of interventions, including
the belief that hormones alone will result in a
perfect or complete transition and may not always
appreciate the vital need to include their parents in
the decision-making processes around hormones.
[83] Professionals managing GAHC in this context
should consider collaboration with professionals
skilled in assessing and managing ASD. Adolescents
and their parents/legal guardians should receive
psychoeducation, and parental/legal guardian
involvement is a crucial support.[83]
2.2.5 Informed consent for surgery in adolescents
Section 129(3) of the Children’s Act states:[73]
‘A child may consent to the performance of a surgical
operation on him or her or his or her child if:
a) the child is over the age of 12 years; and
b) the child is of sucient maturity and has the
mental capacity to understand the benets,
risks, social and other implications of the surgical
operation; and
c) the child is duly assisted by his or her parent or
guardian.’
At the Center for Gender Surgery at the Boston
Children’s Hospital, a policy is followed for two-
parent consent for surgery for adolescents under 18
years, except for cases in which such a requirement
appears to interfere unduly with the informed choices
of minors and raises the possibility of signicant
24 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
harm.[84] Their position is that the involvement
of both parents, as well as psychosocial health
providers in the process of determining eligibility for
surgery, as well as a frank and open discussion with
the interdisciplinary team of the benets and risks
(including possible regrets), serves as a check on the
possibility of impulsivity and reduces the likelihood
that age-related cognitive factors would lead to
decision regret.[84] The role of parents is regarded as
more than IC, as they provide support throughout
the gender-armation process. Boskey et al.[84] point
out that many transgender youth have complicated
family situations, which may make acquiring two-
parent consent to perform surgery on an adolescent
unfeasible or even impossible. Additionally, in South
Africa many children and adolescents do not live with
both parents, and some do not live with either parent.
Therefore, consent is further complicated legal
guardians may be reluctant to agree to treatments
with long-term eects, given their temporary care of
the child (e.g. a social worker in a children’s home).
In line with international best practice for GAHC,
we recommend that the IC process for gender-
arming surgery for an adolescent should involve
a multidisciplinary team that includes an MHP,
surgeon, the TGD adolescent and the parents/legal
guardians.[17,18,84]
2.3 Informed consent in adults
2.3.1 Informed consent for psychosocial care for
adults
According to South African law, a person is
considered an adult at 18 years of age. A client’s
“decisional capacity” is presumed to be intact if they
can understand relevant information, appreciate
the consequences of the situation and reason about
proposed gender-arming treatment. A client’s
decisional capacity should not be judged simply
based on their demographics and mental health
history. Referral to a MHP may be appropriate if
there is doubt regarding the client’s decisional
capacity, such as may occur in the case of severe
mental illness. There are a few other situations,
although rare, where decisional capacity may be
of concern. Some examples might be active severe
substance use disorders, active psychotic disorders,
neurocognitive disorders, severe mood disorders
and severe personality disorders.
The MHP needs to inform the client about the nature
of the therapy/counselling/support and the limits
of condentiality.[85] The client can then consent
to possible evaluation, support and counselling
as discussed with the MHP. ‘The informed consent
model for gender-arming treatment seeks to
acknowledge and better support the patient’s right
to, and capability for, personal autonomy in choosing
care options without the required involvement of
a mental health professional. Clinicians’ use of the
informed consent model would enable them both
to attain a richer understanding of transgender
and gender non-conforming patients and to deliver
better patient care in general’.[86]
2.3.2 Informed consent for hormone therapy for
adults
Using the informed consent model (ICM), clinicians
prescribing HT for TGD clients do not require a
letter from an MHP. This model is understood along
a continuum, with some professionals regarding
IC as the only condition for HT, whereas others
view it as a collaborative decision, giving weight
to both the client’s autonomy and the prescribing
clinician’s assessment.[58] Schulz[60] describes ICM:
‘clients and practitioners are viewed as partners:
the practitioner is viewed as having unique skills
and clinical knowledge, while the patient is viewed
as having knowledge of their own beliefs, personal
value systems, and individual conception of self
with regard to transgender identity’. The goal of the
ICM is not to assess for a psychiatric diagnosis of
‘gender dysphoria’, which could be experienced as
pathologising, but to facilitate thoughtful decision-
making, preserving the client’s autonomy.[71] An
ICM recognises that, in many cases, transgender
persons know more about their needs than many
clinicians, given the lack of training in the eld of
transgender health.[87] A study of an ICM for HT in
Australia reported high patient satisfaction,[61] with
92% of the individuals seeking HT only assessed
by a general practitioner (GP), and 8% referred for
a mental health assessment prior to HT initiation,
mostly due to schizophrenia and post-traumatic
stress disorder (PTSD). Although 56% of participants
had co-occurring mental health conditions such as
depression, anxiety, attention-decit/hyperactivity
disorder (ADHD), ASD or bipolar disorder, this did
not aect their capacity to consent to HT.[61] The
authors state that HT providers should have mental
health experience, which is in the scope of practice
of primary care, and that normalising GAHC into
routine primary care practice will reduce barriers to
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accessing care.[61]
2.3.3 Informed consent and psychosocial
assessment for surgery for adults
Toivonen and Dobson[57] argue that a higher
standard of care – and one that can be justied
from a medical ethics perspective – is medically
necessary for gender-arming surgery, stating that
‘letters of recommendation from mental health
professionals are not meant to create unnecessary
barriers for those who require intervention, but
serve as a safeguard against uninformed decisions
due to signicant consequences’ of gender-arming
surgery. Selvaggi[88] states that psychosocial care
for TGD individuals prior to surgery is a form of
responsible care, and not unjust discrimination: ‘With
regard to referral to mental health professionals, in
our view, its aim is not to demonstrate that there is a
pathology that needs to be cured’. The author argues
that the MHP can assist the surgeon in evaluating the
client’s expectations, and whether the surgery could
positively impact the client’s life, especially when the
surgeon is going to perform irreversible surgery.[88]
The WPATH SoC-7[18] approach has been criticised as
being ‘overly cautious’, though with recognition that
professionals adjust the balance between autonomy
and nonmalecence based on risk.[89]
Florence Ashley, a lawyer who writes about her
experience as a transgender woman, describes IC
for gender-arming surgery as a puzzle, with MHPs,
surgeons and the TGD community holding dierent
puzzle pieces.[90] She argues that, ‘with the focus
starkly placed on the anatomy, it can be easy to
forget that trans patients seeking transition-related
surgeries have a complicated relationship with their
bodies and frequent mental health issues, especially
anxiety and depression’.[90] In her view, MHPs are
better equipped to attend to the client’s overall
well-being and integrate concerns of psychological
and practical preparedness for surgery into their
interactions. The MHP’s role is described as ensuring
the patient has realistic expectations, is ready to
undertake the treatment plan, has an adequate
support system, and has arranged aftercare.
‘The expertise of mental health professionals
complements that of surgeons’ and they are tasked
with assessing and supporting trans clients partly for
that reason’.[90] In addition, trans communities can
play a role in helping to ensure that a TGD person has
adequate information related to the pre-operative
preparation and post-operative care.
For gender-arming surgery in South Africa, a
documented process of thorough IC is essential
and, ideally, should be done together with a
multidisciplinary team that includes an MHP. If the
client is able to consent, then their autonomy should
be respected and facilitated,[18] and it is recommended
that in the case of an MHP writing a referral letter
to a surgeon, this is written in collaboration with
the client in a participatory way.[2] We note that the
WPATH SoC-7[18] 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.[89,90,91] Version
8 of the WPATH Standards of Care is expected at the
end of 2021 and is anticipated to include updated
recommendations.
2.4 Informed consent for adults with
intellectual and developmental disabilities
and who have limited capacity to consent
The considerations discussed throughout this
document apply to person(s) with intellectual and/
or developmental disabilities (PWIDD) – across the
lifespan. It goes without saying that they are not a
homogenous group and the particularities of their
disabilities and experiences vary. An individualised,
person-centred approach is necessary. However,
there are general considerations which can help to
obtain true IC from someone with an intellectual and/
or developmental disability. Ideally, a professional
with competency in working with PWIDD needs to be
a part of this process.
‘Intellectual and developmental disabilities’ is an
umbrella term for a wide range of diculties which
impact on a person’s intellectual and adaptive
functioning, their ability to complete daily tasks
and to learn new things, with the onset during
the developmental period. The term ‘intellectual
disability’ has replaced what used to be referred
to as ‘mental retardation’, not only to minimise
stigma, but to change the way we conceptualise
neurodiversity. ‘Retardation’ implies that the person
is ‘stunted’ or lacks in ability, whereas ‘disability’
speaks to a person’s support needs. Similarly, it is no
longer considered appropriate to refer to someone
as ‘high functioning’ or ‘low functioning’; instead, it
should be framed as the degree of support needed.
This is important to keep in mind when assessing
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consent – your focus is on how you can support the
person, not on their capabilities.
2.4.1 Relevant legislation and frameworks
Several laws should be considered: the Constitution,[4]
Children’s Act[73] (where applicable) and Mental Health
Care Act (No. 17 of 2002)(MHCA).[92] However, these laws
fall short of fully covering the rights and responsibilities
of PWIDD.
The South African Department of Social Development’s
White Paper on the Rights of Persons with Disabilities[93]
acknowledges that ‘persons with disabilities remain
the group whose legal capacity is most commonly
denied in legal systems worldwide’ and therefore
includes a directive to ‘develop supported decision-
making services’, especially for persons with
‘intellectual, psychosocial, neurological and severe
communication disabilities’ (p.102). This directive is
yet to see practical implementation.
It is for this reason that we can draw on the United
Kingdom (UK) Care Act 2014,[94] which aims to
safeguard vulnerable adults from neglect and abuse;
the UK Mental Capacity Act 2005 (MCA)[95] – a legal
framework which supports a person’s right to make
their own decisions; as well as the National Institute
for Health and Care Excellence (NICE) guidelines
and quality standards,[96] which provide insights on
how to assess capacity in PWIDD. Additionally, South
Africa ratied the United Nations Convention on the
Rights of People with Disabilities (CRPD) in 2007,
accepting all legal obligations demanded by the
Convention. The CRPD aims to promote, protect and
ensure the full and equal enjoyment of all human
rights by persons with disabilities. However, South
Africa is yet to integrate international prescripts into
domestic legislation for PWIDD.[97]
2.4.2 Person-centred planning
‘Person-centred planning is concerned ultimately
with supporting people with intellectual disabilities
to choose and experience the lives of their choice
and with social change that enables people with
intellectual disabilities to take their place as full
members of local communities’.[98]
Several person-centred planning models exist which
share the same key principles and values. First and
foremost, the centrality of the PWIDD, who should be
supported as much as possible to take a leadership
role, so as to aord the freedom to plan a life with
the requisite support, rather than merely access to a
service. With this, comes acceptance of the PWIDD’s
authority and responsibility to contribute towards
and control resources, with the backup from others
of their choice. It is essential to include their families/
carers/guardians and to consider wishes and
feelings of these individuals, as they will also need
to understand and appreciate the PWIDD’s need
for GAHC and be motivated to assist. Carers and
families are the primary reason why PWIDD default
on treatment and/or do not attend appointments.
Their perceptions of the ‘benets and burdens’ of
GAHC will signicantly inuence the outcomes for
the PWIDD.
Lack of choice is a common experience for PWIDD.
It is preferable for PWIDD to be aorded a number
of choices (within certain parameters) rather than to
limit the opportunity for them to exercise preference.
PWIDD have the tendency to be agreeable in an
attempt to not upset others and, therefore, do not
protect themselves. By giving them multiple options
to choose from, the chances of this happening are
minimised. For example, instead of ‘Do you want x?’,
say, ‘Do you want x, or do you want y?’
At the heart of person-centred planning is self-
determination, so that PWIDD can direct and control
their personal growth and development. They
should be aorded the opportunity to set their own
goals and be given help in identifying what they may
need to achieve these, and to identify and address
the barriers to their participation.
Persons with severe and profound intellectual
disability will very rarely be able to communicate
their gender identity preferences, let alone have
the necessary executive functioning skills to make
and communicate informed decisions. This is where
alternative-augmentative communication (AAC) and
substitute (or, surrogate) decision-making becomes
relevant. Substitute decision-making comes into
play after it has been determined that the person
does not have the capacity to consent and that all
practical steps to enable the person to make their
own decision have been exhausted. Those who are
responsible for the person’s care and well-being, or
who have been given the legal authority, will make
the decision on their behalf, based on the best
interest of the PWIDD. Respect of their right to bodily
and psychological integrity must be upheld.[97]
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Keep in mind that this may be one of the rst times
someone is listening to them and talking with them
about their gender identity, and they may not
have the language to describe their experiences or
awareness of all possibilities. Their eorts to share
their thoughts and feelings about their gender may
have been dismissed or rejected, leading them to
feel frustrated, lonely and depressed. This could
manifest in psychological and behavioural problems.
[99]
Because PWIDD have the right to be understood, the
NICE Guidelines on Mental Health Problems in People
with Learning Disabilities: Prevention, Assessment
and Management (NG54)[96] provide clear and
concise recommendations on involving PWIDD, and
their family members, carers and care workers, in
mental health assessment and treatment.
2.4.3 Communication (taken from NG54)[96]
Consider the client’s communication needs and level of
understanding throughout assessments:
• speak to the client directly rather than talking
about or over them
• use clear, straightforward and unambiguous
language
• assess whether communication aides (an
advocate or someone familiar with the person’s
communication methods); assess communication
diculties/needs including augmentative-
alternative communication (AAC) needs are
needed
• make adjustments to accommodate sensory
impairments (including sight and hearing
impairments)
• explain the content and purpose of every meeting
or session
• use concrete examples, visual imagery, practical
demonstrations, and role play to explain concepts
• communicate at a pace which is comfortable
for the person, and arrange longer or additional
meetings or treatment sessions if needed
• use dierent methods and formats for
communication (written, signing, visual, verbal or a
combination of these), depending on the person’s
preferences
• regularly check the person’s understanding
• summarise and explain the conclusions of every
meeting or session
• check that the person has communicated what
they wanted.
2.4.4 Informed consent in the context of
intellectual and developmental disabilities
In the context of intellectual and developmental
disabilities, it can be unhelpful to view capacity as ‘all or
nothing,’ or ‘have or have not,’ but rather that it comes
in varying degrees. PWIDD often have diculties with
working memory, self-motivation, inhibition, mental
exibility and abstract thinking, among other things,
which can deter their capacity to make an informed
decision. The UK MCA (2005)[95] advises that it must
always be assumed that the person has capacity,
unless it is proved otherwise, and that you must not
assume incapacity simply because someone makes
an unwise decision.[100] A PWIDD may not be able to
completely make an independent or autonomous
choice, but through a facilitative process they can be
assisted to come to a decision.
It is important to be transparent and explain to the
PWIDD that you are talking to them to conrm that
they can consent; in other words, that you need to
know if they can communicate their choice to you, that
they have an understanding and appreciation of that
choice, and are able to rationalise or explain why they
have made that choice. Simply put, they need to be able
to tell you what their situation is (i.e. that they want to
transition, or want to know more about transitioning),
what their options are and the possible outcomes, risks
and benets and why they are choosing one thing over
another. Their account may be very concrete and focus
more on descriptions of appearance or behaviour than
abstract ideas about gender identity, expression and
feeling.
It is important to remember that capacity to consent
is situational and can change over time and place, and
this is true too for PWIDD. Just because a client has
intellectual or developmental disability does not mean
that they do not have the capacity to learn and gain an
understanding of GAHC, and so it must be considered
whether they will have capacity in the future. In
accordance with the legislation mentioned above, it
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is therefore important to empower the client with
accessible knowledge and understanding of gender
identity and GAHC, and give the time needed to learn,
explore and ask questions. The issue of consent should
be revisited if there is concern that they do not have
capacity at that point in time.
2.4.5 Consent, capacity and decision-making
(taken from NG54)[96]
Assess the client’s capacity to make decisions
throughout assessment, care and treatment for the
mental health concern on a decision-by-decision basis.
Help clients to make decisions by ensuring that their
communication needs are met, and if appropriate, by
involving a family member, carer, care worker or other
individual familiar with the person’s communication
abilities.
Sta delivering care to clients with learning disabilities
and mental health problems should:
• discuss the assessment process and treatment
options with the client and provide information
in a format and language suited to their needs,
including:
– potential benets
– potential side eects or disadvantages – the
purpose of treatment
– outcome measures, including patient reported
• ensure that the client understands the purpose,
plan and content of any meeting or intervention
before it starts, and regularly throughout
• address any queries or concerns that the client
may have at any stage
• allow enough time for the client to make an
informed choice if they have decision-making
capacity, and if they do not, then provide enough
time for their family members, carers or care
workers to contribute fully.
Additionally, the Montreal Cognitive Assessment –
Learning Disabilities (MoCA-LD) has shown promise
in assessing decision-making capacity in persons with
intellectual disabilities. The MoCA-LD is an adapted
version of the MoCA which uses the clock drawing,
trail making, copy cylinder, naming, delayed recall,
digit span (forwards and backwards) and orientation
subtests. It can be used to increase objectivity in
screening for the presence of capacity, but should not
be used to conrm the absence of decision-making
abilities.[101,102]
A signicant barrier to GAHC for PWIDD is the lack of
availability of information in accessible formats. An
easy-read guide has been developed for TGD PWIDD
to understand what they are experiencing and is freely
available online.[103]
In summary, for healthcare providers working
with PWIDD, it is key to prioritise transparency and
accessibility to support the person’s self-determination
and right to access healthcare. Where full IC cannot
be provided, shared decision-making practices can be
adopted, which continue to uphold the autonomy and
centrality of the person in setting out a clear vision for
their GAHC. Referring to, or consulting with a health
provider familiar with intellectual and developmental
disability services is good practice and is highly
recommended.
29 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
PRIMARY CARE
CHAPTER 3
This chapter discusses aspects of comprehensive care that are specic to TGD clients, including sexual and
reproductive health. The process of hormone prescribing is detailed in Chapter 6: Hormone therapy.
3.1 Importance of the primary care
provider
The TGD population is a marginalised group that
faces many barriers in accessing healthcare.[25] A
study conducted in KwaZulu-Natal reported that
there is a paucity of facilities, resources and targeted
programmes to cater for the TGD population’s
sexual and reproductive health needs.[24] Many of
the participants conrmed that they engage in high-
risk behaviour, comprising unprotected sex and
the use of cross-gender hormones without medical
supervision. Furthermore, the participants reported
experiences of hostile and discriminatory behaviour
by healthcare workers. The study concluded that
the training of healthcare workers will contribute
towards improvement of healthcare access for the
TGD population.[24] GAHC requires an innovative
approach with the key elements: person-centred,
gender-responsive, comprehensive care; collaboration
between TGD persons and practitioners; as well as
continuity of care.[104]
To enable broader access, the provision of GAHC
services, especially HT, needs to move away from
specialist clinics and into primary care.[50,105] GAHC
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.[70] The role of primary care nurses
can include the establishment of TGD-friendly primary
care services, monitoring of TGD on HT, education on
HIV prevention and treatment, initiation of clients on
antiretroviral therapy (ART) when indicated, referral to
higher levels of care when required, as well as post-
surgical care.
Delivery of HT by primary care providers using the ICM
can be done safely and eectively for adult clients, with
specialist endocrinologist care needed only for complex
cases,[106] such as underlying medical conditions that
warrant careful introduction of therapy, or metabolic
concerns where drug therapy may aggravate medical
conditions. Specialist involvement may also be of
great value for an adolescent client, but case-by-case
decisions should be made within a multidisciplinary
team context.[17] An analogy would be ART in South
Africa, which was initially only prescribed by specialists,
but has become part of the basic competencies
expected of a medical graduate.[36,107]
Sexual health requires ‘a positive and respectful
approach to sexuality and sexual relationships, as well
as the possibility of having pleasurable and safe sexual
experiences’.[108] A sex-positive approach recognises
that each person’s sexuality is unique and multifaceted
and emphasises the importance of sexual pleasure,
freedom and diversity.[109] This approach is of particular
importance for health professionals who provide
care to TGD clients, to be open to diversity in sexual
practices.[80]
3.2 Comprehensive care
Screening is part of prevention and providing
comprehensive primary care. When caring for a TGD
client, specic attention needs to be given to the
following areas:
3.2.1 Violence
Many TGD persons are reluctant to access health
services, even when experiencing violence.[28] A
trauma-informed approach is to understand that
many clients present with complex trauma histories
with interpersonal, social and medical systems-based
trauma experiences, that may impact on their current
health.[51] Trauma-informed primary care includes
screening for: 1) recent abuse, including intimate
partner violence; 2) lifetime trauma; and 3) emotional
and physical consequences of trauma, including PTSD,
depression, suicidality, substance use and chronic pain.
[110] A patient’s disclosure of recent or past trauma can
be potentially therapeutic, if the health professional’s
response is empathetic and supportive; validates
individuals’ experiences, choices and autonomy; and
30 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
builds on patient strengths. Referral for psychosocial
and legal support may be required; while community
resources and peer support can play an important
role.[110] As the need for support may be beyond what is
available at the health facility, it is important to be aware
of TGD-friendly community resources for referral. See
Appendix D for a list of community resources.
The World Health Organization (WHO) recommends
the LIVES approach to violence (Listen, Inquire, Validate,
Enhance safety and provide Support).[111] 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.[112] If a
forensic examination needs to be performed, then
this requires extreme sensitivity from the health
professional, as a TGD client may nd it very traumatic.
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-arming treatment may have.[113,114] In
South Africa, among a cohort of 85 transgender adults,
the incidence of anxiety was 25.9%, substance use
was 21%, eating or psychotic disorders was 2.3%, and
lifetime prevalence of mood disorder was 21.2%.[115]
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 oered mental health
support[17,18] and continued support should be
encouraged and facilitated, regardless of the client’s
mental health status.[60]
A mental health condition is not a contraindication to
initiating HT, and can be managed concurrently.[18]
Referral is required if there is concern about decision-
making capacity or if a mental health condition needs
to be addressed. While the presence of some mental
health disorders (particularly those with manic or
psychotic features) may aect 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.[116] An Australian
study[61] found that GPs needed to refer only 8% of their
TGD clients to a MHP prior to hormone initiation. Most
of these clients had either schizophrenia or PTSD. Over
half (56%) of TGD clients in this study had a mental
health condition, such as depression, anxiety, ADHD,
ASD or bipolar disorder; however, this did not aect
their capacity to consent to HT.[61]
3.2.3 Screening for alcohol, tobacco and drug use
A national survey reported much higher alcohol use
in transgender participants (n=194), compared to the
general population, with 48% of transgender women
(TGW) and 49% of transgender men (TGM) consuming
alcohol at hazardous, harmful or dependence levels.[25]
These harmful drinking practices are associated with
a lifetime experience of physical or sexual violence.[25]
Tobacco use was reported in 54% of TGW and 50% of
TGM. High levels of harmful and dependent drug use
were found in TGW (29%) and TGM (16%).[25] In a survey
of 258 TGW in eight provinces in South Africa,[117]
58% reported smoking cigarettes; 60% drank more
alcohol than they thought was socially acceptable;
39% reported smoking marijuana and 31% disclosed
that they used other habit-forming substances. Of
participants, 36% responded that they had used
alcohol or drugs to cope with the mistreatment that
they face due to their gender identity.[117]
It is recognised that gender minority stress can
contribute to harmful alcohol and drug use.[118]
Clinicians must be mindful that tobacco, alcohol
and drug use can be coping mechanisms for TGD
persons,[117] thus screening is essential. Tobacco use
in combination with oestrogen therapy is associated
with an increased risk for venous thromboembolism
(VTE).[17] A sensitive and client-centred approach within
a harm reduction framework is recommended, as
described in the Southern African HIV Clinicians Society
Guidelines for Harm Reduction.[119] This includes
screening, brief intervention and referral to treatment
(SBIRT) for harmful substance use.[119] Clients should
be reassured that use of substances will not preclude
them from accessing HT.
3.2.4 Fertility and contraception
A discussion on the impact of HT on future fertility is
essential prior to initiation of HT and is discussed in
Chapter 6: Hormone therapy.
Reliable contraception options must be explored in an
AFAB client who has a uterus and ovaries, as pregnancy
is still possible, even if the client is taking testosterone.
[120] Non-hormonal intrauterine devices (IUDs) are
recommended, to avoid the hormone eect from
hormonal birth control forms, but also the perception
31 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
of the hormone eect, which can be frightening to an
AFAB client.[120] Hormonal options such as hormone-
releasing IUDs, progesterone injections or implants
can be discussed,[120] and would need to be tailored to
the individual’s needs, with an especially keen focus on
the emergence of any side eects.
Transgender men (TGM) who desire children may
consider pregnancy. A cross-sectional study of 41 TGM
who experienced pregnancy, reported that in 80%,
menstruation resumed within 6 months after stopping
testosterone and most TGM became pregnant within 4
months of trying to conceive.[121] For lactation in TGM,
the term ‘chest feeding’ is preferred.[122] There are
reports of lactation even after chest masculinisation
surgery, although surgery may alter the physical
capacity for milk production.[122]
For transgender women (TGW) wishing to breastfeed,
a protocol to induce lactation similar to one for non-
birthing, cisgender women may be followed, including
the use of medication and pumping.[122] Domperidone
has been used to induce lactation in TGW and is eective
in increasing milk supply with no adverse eects for
infants.[123] Trans clients who choose to pursue these
options need signicant support to overcome barriers.
Paynter[123] recommends that ‘health care providers
must bring open-mindedness, curiosity, compassion,
and creativity to practice lactation support for
transgender people.’
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 done
regardless of HT use,[51] and there is no evidence for
increased cancer risk due to HT.[51]
Cervical screening, human papillomavirus (HPV) testing
and HPV vaccination is essential in a TGD client with
cervical tissue.[124] In South Africa, cervical cancer ranks
as the highest cause of cancer death in persons AFAB[125]
and screening should be done regardless of sexual
orientation or comorbidities.[126] This can be done with
a Pap smear or a vaginal HPV swab test. Some AFAB
clients may nd a speculum examination traumatic,
and client-provider communication that is sensitive
and respectful is critical. In addition to causing cervical
epithelial atrophy, testosterone treatment can induce
vaginal epithelial atrophy that may make passage of
a speculum uncomfortable.[127] Strategies to mitigate
discomfort include the use of a small speculum and
application of a small amount of lubricant to the
speculum.[127] A self-collected vaginal swab for HPV
is an option for a client who is reluctant to have a
vaginal examination.[128] The vaginal swab test for HPV
oers improved sensitivity compared to cytology.[124]
Self-collected vaginal swabs have a sensitivity of 71%
compared to provider-collected swabs for HPV testing
and is a good option for AFAB clients who are reluctant
to have a vaginal examination.[128] Several barriers to
accessing cervical screening exist, particularly for TGM,
and providers need to be aware of these and work to
dismantle them.[129]
In TGW with breast tissue and TGM who have not
undergone complete mastectomy, guidelines for
breast cancer screening for cisgender persons should
be followed. Top surgery dramatically reduces risk
of breast cancer in transmasculine clients; however,
a non-zero risk still remains, and this should guide
screening. As a provider, it is important to enquire
whether the client has a family history of breast
cancer. The Radiological Society of South Africa (RSSA)
recommends annual screening mammography
from age 40–70 years and regular self and clinical
examination.[130] Due to resource constraints in the
public sector, screening mammography focuses on
high-risk individuals.[131]
Prostate cancer has been documented in TGW,
although the prevalence is lower than in cisgender
men.[132] Screening should follow guidelines as for
cisgender men; the Cancer Association of South Africa
recommends prostate-specic antigen (PSA) testing for
age 40–50 years if there is a family history or warning
signs of possible prostate cancer, and PSA testing
every two years for age 50–70 years.[133] If a PSA test
is done in a TGW with a low testosterone level, the
upper limit of normal (ULN) should be reduced to 1.0
ng/mL (rather than 2.0 ng/mL as in cisgender men).
[134] If a prostate exam is indicated, both rectal and
neovaginal approaches may be considered. TGW who
have undergone vaginoplasty have a prostate anterior
to the vaginal wall, and a digital neovaginal exam
examination may be more eective.[135]
3.2.6 Sexual health
A client may engage in high-risk behaviour, and a
detailed sexual history should aid screening and
examination. Avoid assumptions about the client’s
sexual orientation and behaviour, and rather discuss
this in a non-judgmental way with a sex-positive
32 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
approach.[80,109] The goal of the sexual history interview
is not to classify or diagnose the client, but to assess
risk for concomitant STIs, and to identify whether there
is a need for PrEP, for example.
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.[136] Use of
culturally respectful language can enable the reporting
of truthful facts and minimise ambiguity or shame.[137]
This can be done jointly with visual aids or a bilingual
lexicon when necessary.[138] Table 3, adapted from
Stroumsa and Wu,[55] provides recommendations for
how to take a sexual history and the provided isiNguni
alternatives provided in the table acknowledge
respect and personhood – principles which are largely
characterised and embraced by Southern African
ethno-cultural populations.
TABLE 3: Gender-inclusive language for taking a sexual history.[55]
Common practice Recommended practice Suggested culturally sensitive
options for South Africa
• Addressing the client as Mr, Ms
or Mrs
• Call the client in from the waiting
room using their last name only.
• Then ask them: ‘How would you
like me to address you?’ (name
and pronouns).
• Pronouns are not gender-related
in Nguni.
• Titles include: sisi/bhuti/
mfowethu/mama/baba/gogo/
mkhulu.
• Addressing the client in a
gendered manner is a form of
respect for one’s age. The title
loses the last letter when prexing
one’s name, for example, ‘sis’
Phumla’.
• Using the client’s Western name
may not be respectful. Ask the
client which name they would
prefer to use as a sign of respect.
• Asking for and using the client’s
clan name (Izithakazelo/iziduko) is
gender- neutral and respectful.
• Use of binary sex markers (male
or female)
• Use a 2-step gender question:
• What is your gender?
• What sex were you assigned at
birth (i.e. what is stated on your
original birth certicate)?
• Gender = ‘isini/ubulili’.
• Ask: ‘What was assigned on your
birth certicate?’
• Obtaining a menstrual or
obstetric history
• Avoid assumptions about
anatomy.
• Clarify whether the patient has a
uterus.
• Ask: ‘A person that was assigned-
female-at-birth usually has a
menstrual cycle. Do you get your
cycle?’ or ‘Do you often go on your
cycle?’
• Asking ‘Are you sexually active?’;
or
• ‘Are you sexually active with men,
women, or both?’
• Advise the client who the
questions asked might seem
uncomfortable or intrusive but are
intended towards assessing risk.
• Understand that there are many
sexual practices that do not
include penile-vaginal penetration.
• Therefore, rather ask: ‘What kinds
of intercourse do you have?’,
followed by appropriate questions
regarding specic sexual practices
(e.g. penis-in-vagina, penis-in-
anus, vulva-to-mouth, etc. – be
sure to use appropriate language
as informed by the client).
• ‘Sex’ is not usually a term used.
• Ask: ‘In which ways do you and
your partner make each other
happy when you are together/in
the bedroom?’
33 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
• Asking: ‘Do you use condoms?’ • Rather ask: ‘Do you use protection
during sex?’; and ‘What protection
do you use?’
• Ask directly around use of
lubricants, and the nature of
lubricants, to determine if they
are condom-safe.
• Ask: ‘Do you use protection? Does
your partner use protection when
you are together?’
3.2.6.1 Eects of hormone therapy on 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.[80]
Erectile dysfunction can be an expected side eect of
feminising HT.[139] In some cases, this is desirable, but
if it presents a problem for the client, treatment with
phosphodiesterase type 5 inhibitors (such as sildenal)
may be considered.[140]
In a client taking masculinising HT, an increase in
sexual desire and activity is often reported[80] and
clitoral enlargement is likely to occur.[141] The clitoral
growth can be signicant, with a mean maximal clitoral
length of 4.6 cm reported in one study, after one year
of testosterone therapy.[142] These changes are often
desirable, but clients should be counselled before
initiating gender-arming HT to ensure that they are
aware of such possible changes.[143]
Vaginal atrophy may occur due to the hypo-oestrogenic
eect that testosterone has on vaginal tissues[144] and
can be ameliorated with lubricants. If this provides
inadequate relief, topical oestrogen preparations can
be used to return atrophic tissues to health, though
these might give rise to fears in clients of the eects
of oestrogen treatment.[120] Such clients should be
reassured, as well as oered the opportunity to start
with small doses and keep track of any unwanted
eects. A combination of topical oestrogen and
testosterone can also be compounded to oset any
unwanted eects from topical oestrogen treatment
alone.
A TGD client on HT may experience a shift in sexual
orientation over time.[145] A qualitative study reported
that TGD participants described shifts in their sexual
attraction and sexual identities, and described their
sexuality in ways that avoided the use of traditional
sexual orientation labels, instead preferring
descriptions that focused on the characteristics that
guide their attraction, e.g. ‘I like women’.[145]
When taking a history, the provider should elicit
information about non-medical gender-arming
practices that the client uses, if any (see Chapter 4:
Non-medical gender-arming practices).
3.2.7 Sexually transmitted infections
High-risk sexual behaviours such as sex work,
unprotected receptive anal intercourse and multiple
casual sexual partners can increase the risk for STIs
including HIV. There is, however, a paucity of data for
non-HIV STIs such as chlamydia, gonorrhoea, syphilis,
viral hepatitis and herpes simplex virus (HSV), and how
they aect TGW.[146]
In addition, little is known about the prevalence of any
STIs, including HIV, in TGM.[146] In studies of transgender
sexual health, inclusion of TGM has been lacking as
this population is historically dicult to recruit for
research. Similar to TGW, TGM may be emotionally
and sexually attracted to people of all gender identities
and can identify as straight, gay, bisexual, queer, or
with another sexual orientation, resulting in a range of
sexual risk behaviours among this group.[146] A study
in Vancouver found that a common goal of sexual
behaviours among TGM was armation of their post-
transition masculinity, leading many to have receptive
anal sex with cisgender men and avoidance of vaginal
sex.[147]
A study in Australia found that the prevalence of
gonorrhoea has increased over the past decade
among TGW attending sexual health clinics, but
not TGM.[148] This change illustrates why we need to
move beyond including all TGD persons in a single
category, as epidemiological dierences such as this
require dierent responses for reducing infection
and delivering appropriate sexual healthcare. Health
systems must meet the specic sexual health needs
of TGD communities. Not adequately accounting for
gender undermines health surveillance, diminishes
client condence and reduces quality of care.
34 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
3.2.8 HIV
3.2.8.1 Epidemiology
TGD persons are disproportionately burdened by HIV
and have a greater risk of acquiring the virus with an
HIV prevalence of 46% among TGW in South Africa.
[149] TGW are therefore included in South Africa’s
National Strategic Plan for HIV, TB and STIs 2017 - 2022
as a key population.[150] After receiving a diagnosis,
HIV-positive TGW may have challenges accessing
eective HIV treatment, as demonstrated by lower
rates of virological suppression and higher HIV-related
mortality.[151] Multiple sociocultural and structural
barriers negatively aect TGW’s engagement within
the HIV care continuum, contributing to adverse HIV
outcomes.[117] TGW, especially young adults, racial/
ethnic minorities and undocumented individuals, often
experience intersecting discrimination and high rates
of trauma, unstable housing, poverty, incarceration
and unemployment, which all negatively impact HIV
risk, testing and continuing care.[152] Few data exist
on HIV among TGM, likely due to much lower HIV
prevalence.[153]
3.2.8.2 HIV screening and prevention
General guidelines for HIV screening, prevention and
care do not dier for TGD persons; however, HIV
services for TGD persons should address the specic
biological, psychological and social needs of this
population.[51] Public health programmes that reach
marginalised TGD persons may need to be aware of
the need to use specialised/dierentiated approaches
to reach persons at high risk who have not been
engaged/tested – e.g., using social network strategies,
HIV self-screening (HIVSS) or index testing, etc. Peer
outreach workers can play a vital role in engaging with
the TGW community and helping TGW to navigate
clinical and social services.[154]
Condoms and condom-compatible lubricant continue
to be important in HIV prevention. However, TGW
taking HT may nd the use of condoms dicult due to
reduced tumescence.[51] TGW may also lack the agency
to negotiate condom use, especially those who engage
in sex work.[154] For TGM who engage in receptive
vaginal sex, internal condoms may be an option.[51]
HIV counselling and testing services should address
TGD-specic needs, and options such as HIVSS, index
testing and partner notication should be oered.[51]
3.2.8.3 Pre-exposure prophylaxis
Daily oral PrEP with the xed-dose combination
of tenofovir disoproxil fumarate (TDF) 300 mg and
emtricitabine (FTC) 200 mg has been shown to be safe
and eective in reducing the risk of sexual HIV acquisition
in TGW.[156] The 2020 Southern African guidelines
on the safe, easy and eective use of pre-exposure
prophylaxis recommend that PrEP should be oered
to TGW.[157] Drug-drug interactions are not expected
as TDF and FTC have dierent metabolic pathways
from sex hormones.[158] A study with self-reported
adherence to PrEP reported slightly lower TDF levels
in TGW on HT,[159] but a study with directly observed
dosing of PrEP found similar blood concentrations
between TGW and MSM,[158] concluding that the eects
of hormones are small and do not reduce the clinical
protection from PrEP. The latter study also showed
that taking PrEP had no impact on oestradiol or free or
total testosterone concentrations among TGW or TGM,
respectively, which can be reassuring for clients who
are taking HT and PrEP.[158] As other HIV prevention
options such as dapivirine vaginal ring and/or long-
acting injectable cabotegravir become available, TGD
clients should be presented with thorough information
on all available HIV prevention options to facilitate
informed choice. The continued use of PrEP should be
encouraged for TGD clients who are at high risk of HIV
infection.
3.2.8.4 Treatment considerations
HIV and its treatment are not contraindications to
HT.[151] In fact, providing HT in the context of HIV
care may improve engagement and retention in care
as well as adherence and viral load suppression.[51]
Modern integrase strand transfer inhibitor (InSTI)-
based therapy is the ART regimen of choice for a TGD
client with HIV.[160] A dolutegravir (DTG)-containing
regimen is preferred over an efavirenz (EFV)-containing
regimen because it is generally better tolerated (fewer
neuropsychiatric, hepatic and metabolic eects) and
has a very high resistance barrier.[161]
A concern among TGW of potential drug-drug
interactions between HT and ART may lead to sub-
optimal ART adherence.[162] This highlights the need
for appropriate counselling to support adherence.
Oestradiol is partially metabolised by cytochrome P450
(CYP) 3A4 and 1A2 enzymes, posing potential drug-
drug interactions with other medications that induce
or inhibit these pathways, such as non-nucleoside
35 | Gender-arming guidelines – Expanded version - October 2021 ↑ Back to Table of Contents
reverse transcriptase inhibitors (NNRTIs), e.g., EFV
and nevirapine (NVP) which are no longer commonly
used.[160] The iFACT study measured plasma EFV, TDF
and oestradiol in 20 Thai TGW on HT and who initiated
ART with TDF/emtricitabine (FTC)/EFV. The study found
that oestradiol was reduced by 36% (p=0.004), likely
due to CYP induction by EFV.[162]
If the TGD client is on both spironolactone and
cotrimoxazole, frequent monitoring of serum
electrolytes and renal function is indicated due
to a possible drug interaction which may lead to
hyperkalaemia, severe illness and even death.[163]
Particularly close attention should be given if the client
is elderly.[163]
TGW 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 virological suppression and higher
HIV-related mortality in this group.[151]
3.2.8.5 Adherence
Adherence to ART and PrEP should be emphasised.
TGD persons are less likely to be retained in HIV care
due to a plethora of factors including sociocultural,
economic, population and health facility determinants
of HIV care.[117] The community-level issues must be
paid special attention because of their role in creating
social cohesion and establishing an enabling space for
holistic health of TGD persons. Innovative approaches
to ensure that TGD persons remain in HIV care are
required. The use of social media platforms and other
information communication technology should be
used to encourage retention in HIV care services.[164] A
study conducted in Mpumalanga[164] found that TGW
may benet from technological approaches such as a
cell phone applications to serve as a digital reminder
for taking medications. In addition to serving as a
digital reminder, positive and arming messaging can
remind clients of the benets of a healthy lifestyle,
including being adherent to PrEP and ART.
3.3 Physical examination
It is important to note that a physical examination
may cause the TGD client distress. Box 2 provides an
arming approach to a physical examination.[51]
BOX 2: Values underpinning this guideline.
• Adopt a trauma-informed approach, as many
TGD clients nd a physical examination
uncomfortable or traumatic.
• Use correct pronouns and names. This is
especially important in the context of a physical
examination.
• Only conduct a genital examination if medically
necessary.
• Explain to the client why the examination is
necessary and what you will be doing. This can
help reduce anxiety. It is also an important part
of obtaining IC.
• Be aware that the client may use alternative
terminology for body parts – ask them which
terms they would prefer you to use.
• Where possible, adapt procedures to make
the client feel more comfortable (for example,
the client may be more comfortable with self-
swabbing for HPV testing).
IC, informed consent; HPV, human papillomavirus; TGD, transgender and
gender diverse.
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NON-MEDICAL GENDER-AFFIRMING PRACTICES
CHAPTER 4
4.1 Background
Non-medical gender-arming practices are strategies
to modify an individual’s gender presentation,[165,166]
often employed daily by TGD persons, and include
binding, tucking, padding and packing, for a variety
of reasons, such as alleviation of dysphoria and a
perceived need to ‘pass’ as cisgender in particular
contexts (e.g., public spaces and the workplace).[166]
Similarly, a TGD person may not feel the need for any
non-medical gender-arming practices, or may need
only selected interventions.
Knowledge on the types of practices employed by
TGD persons is limited, and very little is known about
associated risks or side eects.[165,167] Resources on
non-medical practices are often spread informally
among TGD persons,[166] and while these tend to err
on the side of caution when it comes to safety (see
below list for example), the lack of empirical knowledge
means that these common-sense approaches to safety
remain unveried:
• https://transcare.ucsf.edu/guidelines/
binding-packing-and-tucking
• https://qwchealth.com/2020/11/09/essential-
tips-for-tucking-strapping-packing/
• https://www.prideinpractice.org/articles/
chest-binding-physician-guide/
In one of the few studies on this topic, Rood et al. [168]
showed that, while non-medical gender-arming