Thembelihle Zwane
10 June 2026
Walk into almost any public clinic in KwaZulu-Natal as a transgender woman seeking hormone therapy, and the experience is likely to follow a familiar and exhausting script. The nurse at the desk does not know what you need. The doctor cannot refer you anywhere. You are sent to another facility, then another, accumulating rejections the way other patients accumulate referral letters. A University of KwaZulu-Natal study that documented these encounters found that transgender people were not just turned away; they were met with hostility, misgendered, and in some cases mocked by the very healthcare workers whose job it was to help them. Some participants, desperate for hormones and finding no medical route, resorted to taking contraceptives unsupervised, a dangerous workaround born entirely of abandonment. This is not a story of exceptional failure. According to the researchers, it is routine.
South Africa’s constitution is among the world’s most progressive on gender and sexual identity. Yet access to gender-affirming care remains dangerously uneven. A 2025 study published in the South African Medical Journal found that while social transition was common among transgender participants in the Eastern and Western Cape, only 32% had accessed hormone therapy, and a mere 2.7% had accessed surgery. Legal transition, changing identity documents, was reached by just 4% of respondents. This is despite the fact that South Africa updated its gender-affirming healthcare guidelines in 2021, and the Psychological Society of South Africa updated its own practice guidelines in 2025. On paper, the framework is there. In the clinic, the waiting room tells a different story.
The consequences of that gap are not only physical. Writing in South African Family Practice in 2025, Dr Elma de Vries and colleagues found that withholding gender-affirming care is associated with increased risk of mental health problems including suicidality, and that no studies have shown hormone therapy harms mental health or quality of life among transgender people.
Medical transition for transgender people in South Africa can involve hormone therapy, surgeries, and changes to legal identity documents. But before any of that, transition is something that happens inside a person, a process of self-recognition and self-naming that often begins in childhood and unfolds across years. Researchers at the University of KwaZulu-Natal who studied the experiences of transgender people in the province found that participants began describing feelings of being in the wrong body from as early as thirteen years old, navigating that dissonance privately and without support, long before they had access to any clinical pathway.
The psychological impact of this unsupported period is significant. The condition known as gender dysphoria, the distress that arises from the mismatch between a person’s gender identity and the gender they were assigned at birth, can cause chronic anxiety, depression, and, in severe cases, suicidal ideation. In a South African study cited by the Southern African HIV Clinicians’ Society, transgender adults showed an incidence of anxiety of 25.9%, a lifetime prevalence of mood disorder of 21.2%, and substance use rates of 21%, often used as a coping mechanism in the absence of better support.
Mental health support and medical transition are not separate tracks; they are deeply intertwined. The Southern African HIV Clinicians’ Society guideline is clear that every transgender or gender-diverse client should be offered mental health support, regardless of their existing mental health status. A mental health condition is not a barrier to beginning hormone therapy; it can be managed alongside gender-affirming care rather than treated as a prerequisite to be solved first. Under an older, gatekeeping model, transgender people in South Africa were required to go through lengthy psychological and psychiatric assessments, often conducted by clinicians with no specific training in gender identity, before accessing any medical care. This model caused harm: it pathologised transgender identity, caused significant delays, and reinforced the experience of having to prove one’s own identity to a sceptical institution. The shift towards informed consent, where a person can access hormone therapy based on their own articulated needs and a clinician’s assessment of decision-making capacity, represents a significant improvement, though it has not been uniformly adopted across the country.
For those who do access gender-affirming care and are met with competent, compassionate support, the mental health benefits are well-evidenced. Hormone therapy has been associated with significant reductions in psychological distress, depression, and suicidality. The alignment between a person’s body and their sense of self that hormone therapy can facilitate is not a cosmetic matter; it is a clinical one, with measurable impacts on quality of life.
No conversation about transgender mental health can ignore the weight of family and community rejection. Research consistently identifies family non-acceptance as one of the most significant risk factors for poor mental health outcomes among transgender young people. In KwaZulu-Natal, where family and community structures are deeply bound up with cultural and religious identities, coming out as transgender can mean losing everything – home, kinship, economic support, belonging.
Transgender activist and media personality, Yaya Mavundla, said, “My existence as a Black transgender woman is a conversation. Whatever I do is a statement in response to those conversations. I am determined to make sure that trans voices are heard, and to encourage transgender people to choose themselves, see themselves, and validate themselves, even if no one else is doing it.”
In KwaZulu-Natal, the community is building what the state has not. Trans Hope, founded by Sazi Jali in Umlazi, is the province’s first transgender-led NGO and now operates across eight districts, training clinics, schools, and hospitals while offering counselling to those rejected by families. At Chris Hani Baragwanath Academic Hospital in Soweto, clinical psychologists Coenderaad Jacobs and Najeebah Noorbhai co-facilitated one of the country’s few public-sector support groups for transgender and gender-diverse people, noting in a 2025 paper that even a single instance of misgendering in a therapeutic setting produces measurable harm, lowered self-esteem, distress, and a feeling of being nullified.
“Because of a scarcity of psychological services rendered in public hospitals to transgender and gender-diverse people, support groups in this setting are essential, both for transgender individuals and for the further development of healthcare professionals.”
Sazi Jali, founder of Trans Hope in Umlazi, KwaZulu-Natal, said, “TransHope was born to be the voice for trans people, because sometimes you cannot speak out if you do not have the language.”
The goal is a South Africa where transition does not require heroism. Where a transgender teenager in Newcastle or Pietermaritzburg can access hormone therapy in their local clinic, see a counsellor who affirms rather than pathologises their identity, and be told, without caveat, without delay, that their life has value and their healthcare needs will be met. That future is not here yet. But Pride Month is as good a time as any to demand it.
Support & Resources
Trans Hope (KZN): transhope.co.za
Gender Dynamix (national): genderdynamix.org.za
OUT LGBT Well-being: out.org.za – 012 430 3272
SADAG 24-hour line: 0800 567 567
