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  • 30/06/2024 20:26 | Anonymous member (Administrator)

    PATHSA responded to an article published in Spotlight, and then in Medical Brief and News24, titled "The Cass Review provides guidance on gender-affirming care: SA’s medical community is now at a crossroads", with this article in Spotlight:

    The original version of our response is below. 

    Healthcare at the Political Crossroads: Why Affirming Treatment for Gender Questioning Youth Matters

    The discourse around transgender healthcare, particularly for children and adolescents, has become increasingly contentious. In a recent Spotlight article, First Do No Harm South Africa (FDNHSA) criticised gender-affirming care for young people, raising several concerns that warrant closer examination. As board members of the Professional Association of Transgender Healthcare South Africa (PATHSA), a dedicated interdisciplinary health professional association, we bring extensive experience and expertise in transgender healthcare to this discussion.

    FDNHSA asks: ‘will the Cass Review’s call to provide compassionate, evidence-based care to vulnerable children be taken seriously?’

    In brief, we say it should be a clarion call for better and more services. The Cass Review, led by Dr Hilary Cass, critically evaluated the UK's Gender Identity Development Service (GIDS), which served trans and gender-diverse (TGD) youth from 1989 until recently. The review identified major operational challenges, such as long waiting lists, inadequate mental health support, and inconsistent treatment protocols. It emphasised the need for individualised care, cautious, evidence-based medical interventions and decentralising transgender healthcare to improve accessibility across the UK.

    In South Africa, similar steps are needed to prevent the collapse of gender-affirming care for youth. Currently, we have only one public service providing care for TGD youth at the Red Cross Children’s Hospital’s Division of Child and Adolescent Psychiatry (DCAP). This service assesses TGD youth with their parents or carers and, if appropriate, refers them to paediatric endocrinology at Groote Schuur Hospital for further evaluation and treatment. For those who can afford it, private endocrinologists, psychologists, and other healthcare providers are available. However, only a small handful of paediatric endocrinologists, most of whom are based in Cape Town, work with TGD youth, leaving much of the country and rural areas without health services for TGD youth.

    While we support the Cass Review’s broad call for more and better services, we place on record that aspects of the Review have been weaponised, particularly the call for ‘caution’. This has been interpreted as a rejection of puberty suppressants and disapproval of social transitioning. In fact, Dr Cass has distanced herself from earlier controversial statements questioning the benefits of hormone therapy for TGD youth. She clarified that the review did not conclude, despite inaccurate but widely-publicised views to the contrary, that puberty-suppressing hormones are unsafe but recommends making them available at different ages and developmental stages alongside a broader range of gender-affirming healthcare based on individual needs. Other, significant, critiques of the Cass Review exist, particularly of its ideological and methodological underpinnings. The fact that Dr Cass, a senior clinician with no prior involvement in gender affirming care, was selected to lead the review is bewildering. As one senior UK psychiatrist observed, “I can think of no comparable medical review of a process where those with experience or expertise of that process were summarily dismissed.” Suffice to say, it remains a contentious document.

    FDNHSA asks: ‘Will the medical societies who have promoted the gender-affirming model revise their position statements and support a less medicalised, more holistic management strategy?’

    Gender-affirming care for youth is far more comprehensive than merely prescribing puberty suppressants and hormone therapy without due diligence. FDNHSA misunderstands the term ‘affirmation’ within gender-affirming care, unsurprising given none of its members have worked in TGD youth services.

    In gender-affirming healthcare, 'affirmation' means supporting youths' exploration with guidance and understanding, without pushing them towards a predetermined outcome. This holistic approach integrates psychotherapy, informed consent, social support, and medical interventions as needed. It is a multidisciplinary model which involves healthcare professionals, families, and individuals to support informed decision-making that respects self-determination and dignity.

    During a meeting with PATHSA and FDNHSA on February 21, 2024, we detailed the rigorous process involved in gender-affirming healthcare. Despite this, FDNHSA provides an oversimplified description of gender-affirming care, detracting from the nuanced, evidence-based approach critical for supporting TGD youth. For example, when this article was republished in Medical Brief, they framed the American Academy of Pediatrics' policy statement, which was named "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents," as “guidance on gender transition” and  falsely claims that it was “written by a single doctor.” In reality, Dr Jason Rafferty led the development with contributions from Dr Robert Garofalo and 35 other members and staff from three separate AAP committees, highlighting a collaborative and comprehensive effort. This intentional distortion raises questions about FDNHSA’s integrity and credibility.

    FDNHSA asks: ‘Will clinicians who have advocated and implemented medicalising treatment approaches for children and adolescents with gender dysphoria find the humility and courage to change their practise?’

    FDNHSA's statement questioning if clinicians will "find the humility and courage to change their practice" is deeply patronising and does not bode well for open and honest dialogue. FDNHSA claim neutrality and present themselves as a voice of reason and objectivity. But their resources webpage reveals anti-trans sentiments. For example, they recommend articles like “The Trans Fad which dismisses gender identity as a transient phase and undermines the legitimacy of transgender experiences (Fact Checked). FDNHSA promotes an “alternative approach,” based on the “gender exploratory model,” which, ironically, lacks long-term data and evidence. FDNHSA's promotion of, and connections to, anti-trans organisations, such as Genspect, which advocates for severe restrictions on transgender care, are noteworthy. We note that Genspect has officially been declared an anti-LGBTQ+ hate group by the Southern Poverty Law Centre in the United States.

    FDNHSA's argument that guidelines should not be written by those who work in gender clinics is nonsensical and overlooks the value of professional experience, as noted above. They are critical of the Southern African HIV Clinicians Society (SAHCS) Gender-Affirming Healthcare Guideline - a comprehensive, context-specific framework developed by 17 healthcare providers and researchers with input from an additional 27 contributors. This is far from the echo chamber FDNHSA implies.

    FDNHSA’s approach aims to dismiss as biased the efforts of those who have been advocating for the rights and health of sexually and gender-diverse individuals in South Africa for decades. By contrast, these advocacy efforts are steeped in respect for human rights, are mindful of social prejudice and respect the inherent dignity and autonomy of all[i].

    In conclusion

    Transgender healthcare for children and adolescents has sparked intense debate globally. As the global north grapples with deep divisions over transgender care, we strive for a different path in South Africa. If the Cass Review, and our own local situation, are to be taken seriously, we need to significantly improve accessibility throughout the country, ensure services are well-resourced, include trained healthcare providers skilled in gender affirming care, and offer comprehensive care that integrates mental health and social services. This calls for a sober and thoughtful approach, not fear-mongering and fruitless attacks on sincere organisations steeped in experience of the field.

    We hope transgender healthcare in South Africa becomes less polarised and we remain focused on what is most important. Young trans people matter and deserve holistic care.

    The authors are all board members of the Professional Association of Transgender Healthcare South Africa (PATHSA): Rev Chris McLachlan, clinical psychologist; Mx Jenna-Lee de Beer-Procter, clinical psychologist; Dr Robin Dyers, public health specialist; Prof Elma de Vries, family physician; Dr Sakhile Msweli, clinical psychologist; Pierre Brouard, clinical psychologist;  Ass. Prof Mershen Pillay, audiologist and speech therapist; Dr Arianne Spitaels, paediatric endocrinologist; Dr Allanah Wilson, psychiatrist; Luh Cele, clinical nurse practitioner. PATHSA is a dedicated interdisciplinary health professional association committed to enhancing the health, well-being, and rights of transgender and gender-diverse individuals in South Africa. Our mission is to advance the understanding, acceptance, and equitable healthcare access for trans communities through education, advocacy, research, and the promotion of best practices. We strongly advocate for, “nothing about us, without us,” and believe that it is imperative for TGD people be included in any debate about their lives and healthcare.

    [i] Be True 2 Me. (2024).

    Department of Justice and Constitutional Development. (2014). National intervention strategy for LGBTI sector. Retrieved from 

    de Vries, E., Kathard, H., & Müller, A. (2020). Debate: Why should gender-affirming health care be included in health science curricula? BMC Medical Education, 20(51).

    Gender Dynamix. (2024). Organisational profile. Retrieved May 31, 2024, from

    Haffejee, S., & Wiebesiek, L. (2021). Resilience and resistance: The narrative of a transgender youth in rural South Africa. Gender Issues, 38(3), 344-360.

    Iranti. (2023). About us. Retrieved May 31, 2024, from

    Luvuno, Z. P. B., Ncama, B., & Mchunu, G. (2019). Transgender population’s experiences with regard to accessing reproductive health care in KwaZulu-Natal, South Africa: A qualitative study. African Journal of Primary Health Care & Family Medicine, 11(1), 1933.

    Macheso, W. P. (2021). Vulnerability and the (im)possibilities of becoming: Transgenderism in contemporary South African life writing. African Identities, 19(4), 473-486.

    Muller, M., De Vries, E., Tomson, A., & McLachlan, C. (2023). An introduction to gender affirming healthcare: What the family physician needs to know. South African Family Practice, 65(1), a5770.

    Müller, A., Daskilewicz, K., & the Southern and East African Research Collective on Health. (2019). Are we doing alright? Realities of violence, mental health, and access to healthcare related to sexual orientation and gender identity and expression in South Africa: Research report based on a community-led study in nine countries. Amsterdam: COC Netherlands.

    Müller, A. (2016). Health for all? Sexual orientation, gender identity, and the implementation of the right to access to health care in South Africa. Health and human rights, 18(2), 195.

    Ngidi, N. D., Ramphalile, M., Essack, Z., & van Rooyen, H. (2020). Exploring queerphobic geographies in Southern Africa. Agenda, 34(2), 18-31.

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    Pickstone-Taylor, S. D., Davids, E. L., de Bever, G. N., & de Vries, P. J. (2024). Demographic and mental health profile of youth in a gender service: An African case series. South African Journal of Psychiatry, 30(0), a2160.

    Pillay, S. R., Nel, J. A., McLachlan, C., & Victor, C. J. (2019). Queering the history of South African psychology: From apartheid to LGBTI+ affirmative practices. American Psychologist, 74(8), 954-966.

    Professional Association for Transgender Health South Africa (PATHSA), & Southern African HIV Clinicians Society (SAHCS). (2024, February 8). Response to First Do No Harm: Why we treat gender diverse youth. Daily Maverick.

    Psychological Society of South Africa. (n.d.). Sexuality and gender division (SGD).

    South African History Online. (n.d.). History of LGBT legislation. Retrieved May 31, 2024, from

    Spencer, S., Meer, T., & Müller, A. (2017). "The care is the best you can give at the time": Health care professionals' experiences in providing gender affirming care in South Africa. PLOS ONE, 12(7), e0181132.

    Tomson, A., McLachlan, C., Wattrus, C., et al. (2021). Southern African HIV Clinicians Society gender-affirming healthcare guideline for South Africa – expanded version. Southern African HIV Clinicians Society.

    Thobejane, T., & Mohale, R. (2018). An exploration on the challenges faced by youth in lesbian, gay, bisexual, transgender and intersex relationships at Mkhuhlu location, Mpumalanga province, South Africa. Gender & Behaviour, 16(1), 11424-11439. Ife Centre for Psychological Studies/Services.

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  • 09/06/2024 10:35 | Anonymous member (Administrator)

    A parent’s response to an opinion piece published on News24 on 30 May 2024, titled The Cass Review on gender-affirming care: SA's medical community now at a crossroads

    Dear News24*, I was appalled to read such a biased commentary by doctors with no experience with trans children/ youth, parents of trans children or gender affirming care. They summarise a UK report that is flawed in nature and compromised by a rising 'moral panic' as children increasingly come out as trans in an environment that finally allows them to. Those fuelling the panic assume that a child comes out to their parents and within a month is taking puberty blockers. It doesn't work like this in life. Parents, like myself, are shell shocked when it happens. Many don't accept it and others, like myself, tell our child we love them, hope it's a passing phase and try to educate ourselves. As the months pass, we realise it's not a passing phase, and we start to confront the journey ahead. We cry, we grieve, we fear the backlash, we are confused. We struggle to find gender/trans aware doctors, psychologists and psychiatrists. Our kids want things to happen quicker, parents want to slow it down. It takes months to see an endocrinologist and it must be done with the support of a psychiatrist.

    Puberty blockers have been used for 40 years for girls with precocious puberty, so why the outcry now is beyond me. There is 40 years of data on puberty blockers and the one side effect of possible decreased bone density returns to normal once the medication is stopped. Parents and children investigate all the side effects and make difficult decisions. Cross sex hormones don't start for years, much to the frustration of many trans children. They watch their friends go through puberty and must wait years to do the same. Less than 1% of children 'detransition' (a horrible phrase) yet the public will focus and amplify that anomaly. Why don't these doctors research the 99% of trans individuals who transition and are happy? And all panic discussion leaves out the consequences of denying a child's right to transition socially and later medically. Trans youth have a 50% suicide rate and in some studies, it is higher. I have watched my child's despair as 'professionals' and adults decide his future. I have watched adults call him an abomination, refer to him as 'it' or 'confused' and even lost a friend because their parents decided my son was now a rapist. My son hides in his bedroom, has panic attacks, won't shower because he had to undress, has swapped schools 3 times and yes, he attempted suicide at 13 and often cuts himself. How about these doctors describe the benefits when a child is allowed to socially and medically transition to their authentic selves? Every day is a fight to keep my child alive. Surely this is a medical issue to be contemplated. Medical aids don't cover gender affirming care. Puberty blockers cost over R6,000 for a 3 monthly injection. Top surgery (removal of the breasts) starts at about R80,000. Many kids have to move to small expensive schools that can support their needs. As such, only the wealthy can truly support their children medically. Trans individuals are less likely to find work, so struggle to cover these costs when they are older. How about these doctors investigate the inequalities of health care in this country, talk to trans individuals about their health care needs and insert gender training into the medical school syllabus instead of meddling with a flawed report? Warm regards Helen

    *This letter was sent to News24 in response to their harmful article. The author gave PATHSA permission to publish it.

  • 04/06/2024 21:24 | Anonymous member (Administrator)

    WPATH hosted a Global Education Institute webinar on GAHC in South Africa in April! The panel consisted of Chris McLachlan, Robin Dyers, Landa Mabenge, Anastacia Tomson, Sakhile Msweli and Elma de Vries. The recording of the webinar can be accessed here:

  • 04/06/2024 21:24 | Anonymous member (Administrator)

    WPATH hosted a Global Education Institute webinar on GAHC in South Africa in April! The panel consisted of Chris McLachlan, Robin Dyers, Landa Mabenge, Anastacia Tomson, Sakhile Msweli and Elma de Vries. The recording of the webinar can be accessed here:

  • 31/05/2024 19:42 | Anonymous member (Administrator)

  • 18/05/2024 20:15 | Anonymous member (Administrator)

    PATHSA Chairperson Chris McLachlan has published an article in the Mental Health Matters Magazine, titled "Navigating Gender Diversity in Healthcare - a Guide for Doctors, Psychologists and Social Workers". It is available here:

  • 15/05/2024 20:53 | Anonymous member (Administrator)

     PATHSA members Simon Pickstone-Taylor and  Graham de Bever were part of an author team who published the first African case series of youth presenting at a gender service in April 2024. The study found that transgender youth of all major racial groups in the province with similar demographic profiles to other parts of the world are presenting to services in South Africa and in need of mental health support and interventions. 

    The article can be accessed here:


  • 13/05/2024 21:57 | Anonymous member (Administrator)

    Opinion piece from the PATHSA Board, commenting on the Cass report.

  • 09/02/2024 19:52 | Anonymous member (Administrator)

    PATHSA responded to an opinion piece by FDNHSA (First Do No Harm South Africa) titled “A call on SA medical professionals to heed evidence on child and adolescent gender distress”. 

    Here is a link to the response that outlines PATHSA's position.

  • 21/06/2023 20:10 | Anonymous member (Administrator)

    Minister of Basic Education

    Republic of South Africa

    Private Bag X603



    Dear Minister Motshekga,

    PATHSA Letter of Acknowledgement, Expression of Appreciation and Support for the Work of the DOBE in the Development of the Draft Guidelines for the Socio-Educational Inclusion of Diverse Sexual Orientation, Gender Identity, Expression and Sex Characteristics (SOGIESC) in Schools.

    The Professional Association for Transgender Health South Africa (PATHSA), an inter-disciplinary health professional organisation working to promote the health, wellbeing and self-actualisation of trans and gender diverse people, wish to formally acknowledge the important work the DOBE is presently undertaking in the development of both the draft Protocol for the Elimination of Unfair Discrimination in Schools as well as the draft Guidelines for the Socio-Educational Inclusion of Diverse Sexual Orientation, Gender Identity, Expression and Sex Characteristics (SOGIESC) in Schools.

    PATHSA, as an NPO, wish to further express our appreciation that the DOBE has not only acknowledged the importance of and the need for both these policy documents which are intended to promote an anti-discrimination ethos in schools but also to promote schools being safe, affirming, and inclusive spaces for SOGIESC learners and adults in the context of school communities where all learners can thrive.

    Members of PATHSA have been involved in several of the activities related to the development of these documents in several stakeholder engagement processes from their inception and ongoing to the present.

    PATHSA wishes to reassure you of our support for the ongoing process through to the completion and promulgation of the documents. These documents will be excellent resources that PATHSA can draw from and utilise in our various prevention, promotion, and intervention activities in the continued professional development of our health professionals who themselves will use these resources in their professional practice in our communities throughout South Africa.

    Best wishes with the ongoing work,

    Chris McLachlan

    Chairperson: PATHSA

    21 June 2023

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