Rooting gender-affirming health care within the public health sector

Aim In South Africa, health care for transgender and gender diverse persons has generally been provided within HIV programming, addressing key populations and has been limited in its reach. This paper provides commentary on work to root the provision of gender-affirming care within the public health sector by providing insights into two different health system implementation processes, namely, the Southern African HIV Clinicians Society’s: Gender-affirming healthcare guideline for South Africa, and the Practice guidelines for psychology professionals working with sexually and gender-diverse people of the Psychological Society of South Africa. A discussion on how health care for transgender and gender-diverse persons has been problematised and represented is also presented to enable health systems learning. Method Utilising an established approach to analysing health policy, an exploratory analysis of the two guidelines was employed to understand how policy problems and framing are constructed within them. Specifically, the study interrogated how health care for transgender and gender diverse persons has been problematised and represented. Findings The representations and processes that have taken place to develop, equip and enable the health system to provide care are discussed. The assumptions, effects, silences and disruptions in the provision of gender-affirming health care are presented and the similarities with early HIV denialism are noted. Conclusion The guidelines and programming efforts for gender-affirming care have been informed by guidance from local and global systematic review processes. Given current geopolitics, some of these services are threatened and have closed owing to changes in foreign donor priorities. There is potential for the National Department of Health to take ownership and provide stewardship of care for transgender and gender diverse persons to address their healthcare needs from primary to tertiary healthcare settings.