Desmond Tutu Health Foundation Urges Systemic Change In Gender Affirming Health Services

Conducted in the Western and Eastern Cape, the study highlights the urgent need for systemic changes in public health provision for one of the country’s most marginalised populations.

Access gap

“This research highlights the urgent gap between need and access to medical gender-affirming care, and is a call for improved provision of these essential services across all levels of the health system,” said Lynn Bust of the Desmond Tutu Health Foundation, who led the research project with contributions from a team of researchers.

Transgender and gender-diverse people are those whose gender identity differs from the sex assigned at birth.

They include transgender women who are people assigned male at birth (AMAB) who identify as women, transgender men who are people assigned female at birth (AFAB) who identify as men, and gender diverse or non-binary individuals who are people whose gender identity does not conform to socially-defined male or female gender norms.

Transgender and gender diverse people face multiple layers of discrimination and stigma in South Africa.

The research surveyed 150 transgender and gender diverse adults, including transgender men, transgender women, and gender diverse/non-binary people.

This marks one of the few South African studies to include a wide range of gender identities, including transgender men and non-binary people, offering a clearer understanding of the health needs and experiences of this often-overlooked population.

The findings paint a stark picture of systemic exclusion. Two-thirds of respondents were unemployed, and nearly one in five reported unstable housing — both factors that impact access to healthcare.

While nearly all respondents had engaged in some form of social transition (99%) and non-medical gender-affirming practices such as binding or tucking (85%), far fewer had access to essential medical interventions.

Systemic neglect

One-third had received hormone therapy, and only four participants had undergone any form of gender-affirming surgery.

Equally concerning, only 4% had legally updated their gender markers on identity documents, despite the majority expressing the desire to do so.

There were substantial gaps between need and availability for medical gender-affirming care, 69% of those who had not yet accessed hormones wanted hormones, and 69% of those who had not yet accessed surgery wanted surgery.

A troubling 9% had reportedly turned to unapproved or black-market treatments, reflecting the consequences of limited access and long waitlists — with gender-affirming surgery in the public sector reportedly facing delays of 15–20 years.

“These gaps represent more than just health system failures — they reflect broader social exclusion and systemic neglect,” said Bust.

“Transgender and gender diverse people face barriers to accessing gender-affirming care at every level, and we need real health system reform to make systems inclusive for LGBTQI+ people.”

Despite these challenges, satisfaction among those who accessed care was high.

However, the low access rates, especially to hormone therapy and surgery, emphasise a massive gap between need and availability.

Key recommendations

Abongile Savuka Matyila of the Desmond Tutu Health Foundation and co-author of the paper shared: “When communities are absent from health research, they are often absent from the interventions and policies that follow.

“By centring the lived experiences of transgender and gender diverse people, this research clearly identifies where health systems must change to ensure their needs are properly met.”

The study makes the following key recommendations for strengthening access to gender-affirming care in South Africa:

1. Expand access to legal transition through integrated pathways between healthcare providers and the Department of Home Affairs.
2. Provide accessible psychosocial care without pathologising clients or being a barrier to entry for other gender-affirming care services.
3. Expand surgical capacity through strengthened referral networks and multidisciplinary teams and advocate for inclusion of gender-affirming surgeries in health insurance coverage.
4. Prioritise access to gender-affirming care services at the primary healthcare level.
5. Strengthen the public health system’s capacity to provide gender affirming care services and make systems more inclusive of TGD people.
6. Address socioeconomic barriers to accessing gender-affirming care for TGD people.
7. Improve education to clients about gender-affirming care options and availability.
8. Standardise comprehensive healthcare provider training on TGD health.

This research is a call to action for South Africa to develop a national response that is inclusive, evidence-based, and grounded in the lived realities of transgender and gender diverse people.