Gender-affirming care in South Africa: A cross-sectional survey of transgender and gender-diverse people in the Eastern and Western Cape provinces, South Africa

Background. Transgender and gender-diverse (TGD) people face significant discrimination in the South African (SA) health system, limiting their access to HIV services and gender-affirming care, which supports an individual’s gender identity when it does not align with their sex assigned at birth. Despite the critical role of these services for TGD people, access to care remains understudied in SA. Objectives. To describe TGD people and their access to and need for social, legal and medical transition, including psychosocial care, hormone therapy and surgery, as well as HIV services, in the Eastern Cape and Western Cape provinces, South Africa. Methods. A cross-sectional quantitative survey design was utilised, with 150 TGD individuals recruited via convenience sampling in the Western and Eastern Cape provinces. Interviews were conducted using structured questionnaires, with data captured on REDCap. Descriptive analysis was conducted using Stata 18. Results. Of the 150 respondents, 74.0% were people assigned male at birth (AMAB) and 26.0% were people assigned female at birth (AFAB). Reported gender identities showed that 68.5% of AMAB respondents identified as transgender women/female, 56.4% of AFAB respondents identified as transgender men/male and 34.0% of all respondents identified as gender diverse or non-binary. Demographics showed a vulnerable population, with 18.7% with housing insecurity and 66.0% unemployed. While social transition was common (98.7%), access to legal transition (4.0%) was very low, as was access to all forms of medical gender-affirming care, with 44.7% of TGD people accessing psychosocial care, 32.0% accessing hormone therapy and 2.7% surgery. Of the respondents who had not legally transitioned, 71.4% wanted to. Most respondents who had not accessed medical gender-affirming care services expressed a need for psychosocial care (77.1%) and hormone therapy (68.6%). Gender-affirming surgery was more variable, with 33.3% of AFAB respondents wanting bottom surgery compared with top surgery (63.9%), and 49.5% of AMAB respondents wanting bottom surgery compared with top surgery (55.9%). Almost all (99.3%) respondents had had an HIV test in their lifetime, with reported HIV prevalence differing between AMAB (34.2%) and AFAB (7.9%) respondents. PrEP uptake among HIV-negative AMAB respondents was 30.4%, and 5.7% among AFAB respondents, while 78.0% of TGD people living with HIV were on antiretroviral treatment. Conclusion. Findings demonstrate a critical gap between needed and actual access to legal and medical gender-affirming care services. There is an urgent need for the provision of integrated and accessible gender-affirming care and HIV services as part of comprehensive care for TGD populations within inclusive health systems nationally.