South Africa’s only state gender-affirming clinic provides surgery to just four patients a year, while receiving up to 10 new referrals a month – with patients joining the list today facing a wait of 20 to 30 years, writes Jacques Malherbe for GroundUp.
The backlog was exacerbated by Covid, health budget cuts, and the collapse of NGO services after international funding cuts. Meanwhile, nearly a third of transgender youth in South Africa have attempted suicide, according to studies, with those unable to access care at particular risk.
Christien Odendaal spent decades feeling trapped by her body.
“From five-years-old, I knew I wanted to be a girl, but I was trapped in a male body,” she says. Growing up in rural KZN, expressing such feelings led to abuse and isolation.
“It completely broke me,” she says. “I tried to commit suicide a few times.”
But eventually, at 47, she informed her wife and two children that she would begin her gender transition.
Odendaal contacted the Triangle Project. Months of counselling and years of hormone replacement therapy (HRT) followed, and eventually surgery at the Transgender Healthcare Clinic at Groote Schuur Hospital.
“I now feel like the person I was always meant to be,” she says.
At 52, Odendaal was one of the oldest patients treated by the clinic, the only state-run facility in South Africa offering integrated gender-affirming care. The clinic provides a pathway that includes psychological support, hormone therapy, and, for some, surgery.
Access to the clinic is through referral from the Triangle Project, an LGBT+ organisation. Next come meetings with the clinic’s psychologists, endocrinologists, social workers, plastic surgeons and other professionals.
But while new access to counselling and hormone therapy is available, surgical care remains severely constrained.
“We can help four people a year and at the moment we are seeing between five and 10 new patients a month,” says Dr Kevin Adams, a plastic surgeon at the clinic.
Patients joining the list today may have to wait 20 to 30 years for surgery.
The lengthy delays caused by the the pandemic, along with numerous budget pressures in the public health system, as well as the shutting down of NGO-run services after international funding was slashed, have worsened the backlog.
“Plastic surgery has lost more operating time than most other departments,” says Adams. “We don’t have enough time to do these operations.”
Larger operations, like vaginoplasties, can take a full day. Smaller cosmetic surgeries are less time-consuming but are considered low priority.
For many patients, the care is not elective but essential. Gender dysphoria – the distress caused by a mismatch between one’s gender identity and assigned sex – can make everyday life deeply distressing.
Routine acts such as getting dressed or using the bathroom can cause anxiety and alienation.
A study by the South African Society of Psychologists found that nearly one-third of transgender youth had attempted suicide, with those unable to access gender-affirming care particularly at risk.
Carol Lennon, chief nurse at Triangle Project, says: “Many new patients are thinking about suicide … Many times they’re kicked out of their church, their family home or they lose friends. It can become very traumatic.”
But with psychological support and hormone therapy, they can stabilise enough to begin navigating the long wait for surgery. For some, this care is experienced as life-saving, a way to reconcile identity and body after years of distress, adds Lennon.
Jackye Majawie is one such patient. She grew up in Worcester in a deeply religious community where transgender identity was never discussed. “I didn’t know anything about transgender people,” she says.
After moving to Cape Town in 2006, Majawie sought help from Triangle Project. “I saw other trans people there and had conversations with them… I reached out for help,” she says.
That journey led her to Groote Schuur’s Transgender Clinic.
After years of counselling, hormone therapy, and more than a decade on a surgical waiting list, Majawie is at last preparing for further surgery. She joined the list in 2014.
The wait has been long and taxing. “I don’t have the means to go private,” says Majawie. “If you want it to be done, you just have to wait.
“To be fully transformed into a body that I feel comfortable in… will be a wonderful experience.”
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Gender-affirming healthcare matters in SA
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Survey confirms difficulties of SA’s key populations in accessing healthcare