9 September 2021
PATHSA would like to respond to views expressed in a seminar titled “What does science says about LGBTQA+”, that was held by the Vice-Chancellor of UCT on 5 September 2021 with Dr. Kgomotso Mathabe, who is a practising urologist and a member of the Steve Biko Academic Hospital’s Gender Clinic.
PATHSA recognises and is concerned with the fact that great pain has been caused by the discussions during the seminar.
We understand that the intention of the seminar was to discuss diversity, and in principle we welcome dialogue that contributes to better understanding of the challenges faced by intersex and transgender and gender diverse people. Access to gender-affirming healthcare and especially surgery is a critical concern.
Gender-affirming healthcare is a field in medicine that is fast evolving, and globally approaches and insights are changing over time. We would like to focus our response here on depathologisation, models of care, and access to care in South Africa.
The Professional Association for Transgender Health South Africa (PATHSA) is an interdisciplinary health professional organisation working to promote the health, wellbeing, and self-actualisation of trans and gender diverse people.
One of the objectives in our constitution is:
“To disseminate awareness around power dynamics that are typically inherent to all health care seeker/provider interactions involving people who are part of the trans and gender-diverse communities, to acknowledge the damage that has been done by such dynamics, and to insist that gender-affirming clinicians must take steps to dismantle these typical power hierarchies.”
We recognise that health professionals have often viewed diverse gender identities as pathology, and in the past classified it as a mental illness. Historically, medical research produced the “scientific” evidence that pathologised sexualities and gender identities that did not conform to societal expectations, as well as supported treatments such as so-called “conversion therapy” that is now regarded as unethical. The depathologisation movement led to the WHO declaring with the publication of the International Classification of Diseases and Related Health Problems (ICD) version 11, that gender diversity is not a mental health disorder. Gender-affirming care models utilise an approach of depathologisation of human gender diversity (transgender as “identity”), rather than a pathological perspective (transgender as “disorder”).
In the statement by the Gender Diversity Coalition on 7 September 2021, the coalition say that “If we state we are Trans, we don’t need medical scrutiny to affirm this.” This aligns with the informed consent model recognised by the World Professional Association for Transgender Health (WPATH) Standards of Care 7 and that is described in the South African guidelines that will be launched in at the Southern African HIV Clinicians Society (SAHCS) conference on 20 October 2021. As health professionals, we have an ethical duty to prevent harm (non-maleficence). In the context of gender-affirming healthcare, such harm can include a health professional taking advantage of power relationships and gatekeeping access to care. In contrast, the Informed Consent model empowers the individual, by upholding their autonomy and maintaining their integrity. The client and healthcare provider become collaborative partners in decision making.
We have a broken health system in South Africa that is not currently able to meet the needs of our people. Transgender and gender diverse people experience huge challenges to access gender-affirming healthcare, especially in the public sector, and this needs to change. In the seminar, Dr. Mathabe correctly pointed out that she is one of very few surgeons in South Africa performing gender-affirming genital surgery. PATHSA acknowledges that only a few surgeons are involved in gender-affirming surgery in South Africa and thus it is crucial for gender-affirming surgeons to advocate for their clients and affirm their self-actualised identities. GEMS (Government Employees Medical Scheme) lists “gender reassignment surgery” for all their plans apart from the entry level “Tanzanite one” plan from 2021, and Discovery Health includes it in some of their plans. Where will we find the surgeons who are skilled to perform these procedures?
In the light of the above, PATHSA recognises the voices of the Gender Diversity Coalition, and we share the goal of “a health care system that is depathologised and affirming of gender identities, gender expression and sex characteristics”.
PATHSA notes that the Gender Diversity Coalition strongly speaks out against 'genital mutilation' of intersex people. Although PATHSA's focus is trans and gender diversity we acknowledge that some members of the intersex community also identify under the trans and gender diverse umbrella. We uphold and respect self-determination of all people in regard to sex, sexuality and gender diversity. As a professional society we uphold the ethical principle of 'do no harm' and do not support any acts of genital mutilation. Furthermore, intersex people's bodies are not seen as pathological and that something is 'wrong' or 'disordered' with their bodies. Diversity in sex development is seen as being part of the spectrum of sex development that is inherently part of all societies. As multi-disciplinary teams of healthcare providers we can offer support, where needed by the intersex individual, or family of the intersex child. Often in the area of intersex children, psychosocial support for the parent(s) to navigate community reactions could be of great value if required by the parent(s). Furthermore, healthcare providers should provide information to counter community stigma and promote inclusion of all bodies. PATHSA upholds depathologisation, not only of trans and gender diversity, but also of all diverse body presentations. As PATHSA we acknowledge that healthcare workers have been and in certain spaces still is, the violator of 'genital mutilation'. We strongly speak out against any act of 'genital mutilation', we see it as a crime and violation against humanity and stand in solidarity with the intersex community who calls for the ending of surgeries performed on intersex infants.
We call on all our professional and academic colleagues to listen to transgender and gender diverse people and intersex people with humility, and to work together to create health services that will respectfully provide the care that is so needed. The need to use sensitive language is critical when engaging with topics around trans and gender diversity and intersex, to avoid causing further harm.
As academics and health professionals, we need to engage in meaningful conversations beyond the traditional dominance held by both the institution of Western medicine and academia; the marginalisation of trans and gender diverse people and intersex people is not ethical and their voices and lived experience must be centralised. We as healthcare providers may not mimic allyship but must be committed to real transformation where oppressive, violent, and marginalising systems are challenged and dismantled.
We believe public seminars are invariably more helpful should intersex or transgender and gender diverse people be consulted, included, and given the first voice to speak and help professionals when they fall short in understanding what is helpful for their communities, hence the activist motto: “Nothing about us without us”.
PATHSA is willing to participate in conversations that lead to a better understanding of the issues and assist in maximising the essential contribution health professionals make to the transgender and gender diverse and intersex community.
PATHSA celebrates diversity, upholds self-determination of sex, sexuality, and gender identity, upholds depathologisation, fights hetero-cis-normativity and supports ethical practices.
For the board of PATHSA