Rapid Review of Gender-Affirming Healthcare for Children and Adolescents: Evidence Synthesis (2021-2025) and Recommendations for South Africa.

Why we need this rapid review: In South Africa, transgender and gender-diverse (TGD) children and adolescents continue to navigate health systems shaped by deep inequalities, limited specialised services, and persistent stigma. Here at home, these young people too often move through environments marked by the legacies of apartheid, economic exclusion, uneven service delivery, and ongoing social prejudice. These layered forms of inequality shape how families, caregivers, teachers, and communities are able to support the young people they love.At the same time, international debates about gender-affirming healthcare (GAHC) for youth have become increasingly polarised, often driven by narratives that do not reflect South African realities or the rights-based framework of our Constitution. Much of this global rhetoric arrives at our shores without acknowledgment of our country's unique social fabric, woven from resilience, cultural diversity, and a deep collective commitment to justice and dignity, even as we continue healing from our past.This rapid review brings together rigorous, peer-reviewed evidence published from 2021-2025 on GAHC for youth under the age of 18 to help us understand what works, what is safe, and what young people need. It builds on the 2021 GAHC Guideline supported by Southern African HIV Clinicians Society (SAHCS), which is South Africa's current clinical framework for gender-affirming care, ensuring that our practices remain aligned with the best available evidence and our constitutional values.It also serves a deeper purpose: it offers guidance to the parents, families, caregivers, educators, health-workers, faith leaders, and communities who are trying to walk alongside TGD children and adolescents with compassion and clarity, sometimes in the face of fear, uncertainty, or misinformation.It reflects the combined expertise of a queer- and trans-led team committed to dignity, equity, and affirming care, which are values consistent with Ubuntu, Batho Pele, and the broader South African human-rights tradition. This is work rooted in the understanding that a young person does not grow or struggle alone; they grow in families, in communities, in classrooms, in clinics, and in the collective dreams we hold for a more just and caring society.This review is therefore not only a scientific exercise. It is an act of accountability. An offering of care. A step toward ensuring that every young person in this country, regardless of gender identity, race, class, disability, or geography, is met with dignity, safety, and support. It is work that recognises our shared responsibility to build a South Africa where all children and youth can thrive. What the evidence shows: Across 200 peer-reviewed research articles, 29 systematic reviews and 4 rigorous technical reports included in this rapid review, one picture emerges clearly, a picture that resonates with common sense, lived experience, and the stories told by TGD youth across the country. When TGD young people receive gender-affirming care within supportive families schools communities and clinical settings they do better emotionally socially and medically: 1.An affirming home, an accepting teacher, a safe clinic, or a supportive friend can dramatically reduce distress, depression, and feelings of isolation. Young people become more confident, more hopeful, and more connected to their communities. Their school attendance improves. Their relationships deepen. Their sense of belonging grows. Non-clinical delays long waiting lists service gaps and administrative barriers worsen distress and mental-health outcomes: 2.Internationally, these structural barriers are consistently linked to poorer wellbeing for TGD youth. In South Africa, many delays have nothing to do with safety or clinical readiness, they stem from limited staffing, uneven provincial capacity, referral bottlenecks, and financial constraints. For young people, these delays are not neutral. They often result in worsening anxiety, deepened dysphoria, and increased risk of self-harm or suicidality. Puberty pausers and gender-affirming hormones work as expected when monitored by specialists: 3.Puberty pausers do not override who a child is; rather, they give young people time; time to breathe, time to grow, time to make developmentally appropriate decisions about their bodies without the pressure of unwanted pubertal changes. Puberty pausers and gender-affirming hormones produce expected and desired outcomes under specialist monitoring. Side effects are usually mild and reversible, and mental-health outcomes are mostly stable or improved. Surgery for young people under 18 is rare almost all evidence relates to chest reconstruction for transmasculine youth: 4.These surgeries are not undertaken lightly, are generally only offered to older adolescents, and are far less common than some public discussions suggest. When masculinising chest surgery is offered, it shows low complication rates and high satisfaction. Many young people report significant improvements in body image, participation in daily life, and overall wellbeing. Policies matter: 5.Policies shape lives. They decide whether a young person can change their name at school, whether a clinic has clear protocols, whether there is protection against discrimination, or whether a family must fight through unnecessary red tape. Restrictive laws are consistently linked to increased distress, self-harm, and suicidality.Protective laws such as anti-discrimination policies and access to legal gender recognition improve mental health and safety.In short: Affirming environments promote healthier outcomes. Restrictive environments are linked to distress and harm. A South African lens: Almost all of the global research on GAHC for youth comes from high-income countries, places with more specialised services, shorter waiting times, and stronger safety nets than those available to most South Africans. Yet the findings are still clear and relevant when interpreted through a local lens. South African youth often face added burdens: 1.Poverty, community violence, discrimination, school-based exclusion, xenophobia, racism, homophobia, and limited access to specialised care all intersect to shape the mental health of TGD young people. These realities amplify the need for safe, affirming services, they do not diminish it. Most medical schemes do not cover GAHC: 2.Even families with medical aid often face high out-of-pocket costs. For many, this makes care inaccessible, reinforcing historical patterns of inequity. Nodal disparities across provinces deepen inequality: 3.Some provinces have dedicated clinicians, while others rely on referral pathways that stretch across hundreds of kilometres. Rural youth often carry the heaviest burden, travelling long distances, missing school, or facing stigma when trying to access support. Our histories matter: 4.South Africa's past left a legacy of fragmented health systems and unequal access. But it also left a legacy of resilience, community solidarity, and a collective instinct to protect our most vulnerable.This makes affirming, timely, and coordinated care even more essential here, not less. Limitations of the evidence: The evidence base is growing, but not perfect, and it is important for families and communities to understand its limitations without misinterpreting them: Most studies are observational, meaning they reflect real-world experiences rather than controlled clinical trials.Follow-up periods are short, especially for adolescents whose needs evolve rapidly over time.Non-binary and neurodivergent youth remain underrepresented, even though they make up an important part of our community.Very few studies come from the Global South, including African nations, where cultural contexts, resource constraints, and support systems differ.Randomised trials are not feasible in this field, given the small population, inability to blind participants or prevent them from accessing related interventions, and the ethical concerns of withholding needed care.These limitations reflect gaps and constraints in the global research landscape, not a lack of benefit. Instead, they highlight the importance of building a stronger African evidence base in the years ahead. Conclusion What this means for South Africa: The findings are remarkably consistent: Gender-affirming healthcare is effective and life-enhancing for young people who want it, with established safety profiles under professional care.This rapid review supports the continued implementation and strengthening of the SAHCS GAHC Guideline. It also calls for policies and services that uphold the constitutional rights, dignity, and humanity of TGD youth.But beyond the science, there is a deeper message for us as a country: When a child is affirmed, they are more likely to stay in school, maintain strong family bonds, build a sense of belonging, and grow into adults who contribute meaningfully to their communities. When a child is denied care and support, we risk losing them to despair, to disconnection, or to preventable harm. The message is simple: When we affirm, young people thrive. When we delay or deny, they suffer.This review is a reminder that every young person deserves care that sees them, respects them, and allows them to grow into who they truly are without fear. It is a call to parents, teachers, health professionals, faith leaders, policymakers, and community members to walk alongside our youth with compassion and clarity.In the spirit of Ubuntu, we remember: A child's wellbeing is never theirs alone. It is held in the hands of all of us.