Southern African HIV Clinicians’ Society gender-affirming healthcare guideline for South Africa

No abstract available.


Executive summary
We support an affirming approach to managing the transgender and gender diverse (TGD) client, centering on the individual's agency, autonomy and right to selfdetermination, as opposed to practices that pathologise and stigmatise transgender identity, imposing barriers to accessing healthcare services.
Transgender and gender diverse individuals have long faced discrimination on multiple axes, both globally and in South Africa. Although South Africa enshrines the protection of human rights in its Constitution, TGD individuals continue to face marginalisation, prejudice and threats to their safety. Challenges, including homelessness, unemployment, poor social support, bullying, harassment and violence, persist, indicating failures of policy development, practice implementation and a disregard for the human rights of individuals in the TGD community.
This guideline has been developed primarily with the intention of centering and amplifying voices of TGD individuals in order to facilitate access to healthcare that is sensitive, skilled and respectful. We recognise that there are significant gaps in the knowledge and skills of healthcare providers, and there is a lack of understanding of the unique experiences faced by TGD persons. The prevailing sentiment that many healthcare providers hold around TGD individuals, informed by ignorance and conditioning within social and societal structures, are malevolent towards this community, and often include harmful assumptions and generalisations. We believe that healthcare providers have an ethical obligation to interrogate these notions, and we promote an attitude of respect for diversity that upholds human rights.
It has been well established that access to competent and dignified gender-affirming healthcare (GAHC) is not only safe but also plays a significant role in improving measurable outcomes for TGD clients. It has also been well established that pathologising approaches and practices that limit access to care can be damaging and harmful.
Finally, we recognise that TGD individuals have historically endured being undermined, condescended to and pitied by the healthcare system and its providers. We affirm a commitment to upholding a strength-based perspective that values and respects the experiences of TGD clients and celebrates their individual identity rather than merely accepting or tolerating it.
This guideline, which no doubt will require ongoing revision, reflection and refinement in consultation with TGD communities and healthcare providers, represents a first step made in good faith towards creating a practical tool founded in robust scientific evidence, lodged within a human rights framework, and is intended to facilitate access to skilled and sensitive care that will yield tangible benefits to this unique and important group.

Scope and purpose
• Provide evidence-informed best practice recommendations in order to enable South African healthcare providers, including psychosocial and allied healthcare professionals, to offer quality, affirming services to TGD clients. The term 'client', for the purposes of this guideline, includes service users, patients and participants. • Provide support to TGD clients when accessing healthcare services. • Note: this publication is a summary version of an expanded guideline, which can be accessed here: https:// sahivsoc.org/Subheader/Index/sahcs-guidelines.

Audience
This includes all healthcare providers, particularly those working in a primary care setting, public or private, or that care for TGD clients.

Methods
The guideline development committee comprised 17 people, chaired by Dr Anastacia Tomson and Rev. Chris/tine McLachlan, which was inclusive, with representation of providers, advocates and civil society organisations in the TGD space, and many with personal experience as a TGD client. Development was predicated on the necessity to amplify the voices of those within the TGD community in order to better meet their needs, rather than presuming that healthcare providers can address those needs alone. This guideline was informed by evidence-based research studies, as well as provider experience from within the field. The committee worked from a gender-affirming, non-gatekeeping, depathologising perspective using a participatory approach that centres on the TGD client's agency and humanity, and upholds their dignity. 1,2,3 Strict values underpin this guideline, as shown in Table 1. In order to ensure applicability to the South African context, focused effort was made to review local research studies. Resources from the global South were then accessed, and only key resources from the global North were incorporated. An extensive, external peer review process was conducted, which included both health provider and community reviews. Guideline development and publication were supported by the Southern African HIV Clinicians Society (SAHCS) through Dr Camilla Wattrus and Dr Lauren Jankelowitz.
of the Professional Association for Transgender Health in South Africa 20 and Psychological Society of South Africa 21 , and the Department of Health's Batho Pele principles. 22 Despite this, many transgender and gender diverse (TGD) individuals struggle to access gender-affirming healthcare (GAHC) services in South Africa.
Gender-affirming healthcare attends holistically to a TGD individual's mental, physical and social well-being, and health needs, whilst respecting their self-identified gender. 23 Each individual has unique needs, and the gender-affirming process is rarely linear. This process may include social and medical elements, or none at all. A client with a non-binary identity may have unique and specific treatment goals: Because for me, my transitioning is more spiritual than physical. I live as a woman every day. My nieces and my nephews, they call me mom, and finding peace within myself and being able to fight for them to have a representation of what love looks like makes me feel fulfilled. Your womanhood is within you more than what is here on the physicality. 24 It is important to note that as a healthcare provider, withholding or delaying treatment is not a neutral action. It can have an impact on the client's mental health conditions and, in adolescents, may have implications on what medical or surgical treatment is required later in life. Gatekeeping (delaying treatment until the healthcare provider feels a particular subjective degree of certainty) is potentially harmful. 11

Informed consent 2.1. The process
Informed consent (IC) in GAHC is complex and nuanced. 25,26 The IC process should empower the individual by upholding their autonomy and maintaining their integrity. 11 Even in a supportive and affirming environment, there is often an unequal power relationship between the client and the healthcare provider. 27 This can be distressing to the client and have a negative impact on their care. 28 The client and healthcare provider should be collaborative partners in decisionmaking. 1,29 The healthcare provider should inform the client of the risks and benefits of the various treatment options, thus enabling the client to make an informed decision about their own healthcare. 30

Hormone therapy and surgery
A healthcare provider wanting to prescribe hormone therapy (HT) does not require a letter from a mental health provider (MHP) in order to do so, and they may perform the psychosocial assessment themselves if comfortable. 6,26 For gender-affirming surgery, a documented process of thorough IC is essential and, ideally, should be performed together with a multidisciplinary team that includes a MHP. If the client is able to consent, their autonomy should be respected and facilitated, 6 and it is recommended that in the case of an MHP writing a referral letter to a surgeon, this be written in collaboration with the client. 2 We note that the World Professional Association for Transgender Health (WPATH) Standards of Care 7 6 states that a client should have two independent psychological evaluations prior to surgery. However, it has been convincingly argued that this is not necessary for all clients. 31

Children and adolescents
The Children's Act states: A child may consent to medical treatment if over 12 years and the child is of sufficient maturity and has the mental capacity to understand the benefits, risks, social and other implications of the treatment. 32 The term 'medical treatment' is understood to be a manifestation of the right to health as provided for in Section 27 of the Constitution of the Republic of South Africa, 7 and includes access to psychosocial and mental healthcare services. 33

Affirmation
We affirm and respect transgender and gender diverse (TGD) individuals, and acknowledge that the full spectrum of gender identities and diversities is valid. 3 We understand that the concept of gender varies in relation to political and sociocultural contexts, personal and intergenerational trauma, and migrant and disability status. 4 We avoid assuming links between the gender role, sexual orientation and gender identity based on traditional, binarised, cisnormative and heteronormative understandings of femininity and masculinity. 5,6 Dignity All people have the right to dignity, 7 and this should be respected and protected. We acknowledge that people whose gender identity and gender expression fall outside of narrow societal norms are subject to stigma, discrimination and even violence. Competent and affirming healthcare upholds personal dignity and is fundamental to protecting and promoting the rights of all human beings.

Equity
We uphold the Yogyakarta principles that state all people are equal, should have equal access to their basic human rights, and no one should be subjected to unfair discrimination. 8 The Yogyakarta principles +10 further stipulate the 'right to freedom from criminalisation and sanction on the basis of sexual orientation, gender identity, gender expression or sex characteristics'. 9 It is important to recognise that some people are subject to intersecting layers of discrimination, such as of race, socio-economic status, geographical area, age, health disparities, transphobia and homophobia, sexism and gender discrimination, and the oppression of women. 2 It is the role of healthcare providers to challenge all forms of stigma, abuse, inequality and oppression directed at the TGD minority. 3 Inclusion TGD individuals should be included as equal partners in making decisions about their own bodies and healthcare, and also in broader decision-making regarding laws, policies and guidelines that have impact on their access to healthcare services.

Informed consent
Healthcare providers and clients are partners in making choices about medical treatment: the provider should inform the client of the risks and benefits, and the client should make an informed decision about their own healthcare based on the information provided. 10 This approach respects a client's agency over their own body, and is both clinically safe and ethically sound.

Ethical principles in healthcare
These include autonomy (self-determination and agency), non-maleficence (no harm), beneficence (benefitting the client with access) and justice (fairness and equity). 11 The healthcare provider is ethically obligated to treat the TGD client with dignity and respect, and to facilitate access to care (both general and gender-affirming) without gatekeeping or judgement.

Ubuntu -the participatory approach
Umuntu ngumuntu ngabantu -A person is a person through other people. The African concept of Ubuntu is central to South Africa's democracy. It calls on us to view the inherent humanity in all people and helps us to understand human interdependence within the indigenous context. All people need to be seen, recognised and affirmed as who they are in order to live fulfilling human lives. 12,13 Batho Pele These eight principles aim at enhancing the quality and accessibility of government services by improving efficiency and accountability They include consultation, service standards, access, courtesy, information, openness and transparency, redress and value for money. 13,14,15 Trans giftedness TGD individuals are generally resilient, self-aware, possess inner strength, and have unique perspectives and insights. 16 This enables them to engage with the world of gender in new and diverse ways. 17 We acknowledge this and utilise a strength-based perspective rather than condescending to, undermining or pitying TGD individuals.
TGD, transgender and gender diverse.
If an adolescent desires puberty blocking medication, HT or surgery, the IC process requires involvement of a multidisciplinary team, including both mental health and medical or surgical providers. 34 It is recommended that both parents and legal guardians be included in this process wherever possible, 5 as improved family support is associated with better mental health outcomes in TGD adolescents. 35,36

Intellectual and developmental disability
Individuals living with intellectual or developmental disability have the right to access healthcare services. 37 This includes TGD individuals who may have limited capacity to consent to gender-affirming treatment. Where fully IC cannot be provided, shared decision-making practices should be adopted, in which the client's autonomy in the process is upheld. 38

The importance of the primary care provider
The TGD population is a marginalised group that faces many barriers in accessing healthcare services. 39 Currently, there are few facilities, resources and targeted programmes to cater for this population's specific sexual and reproductive health needs. 40 In order to enable broader access, the provision of GAHC services needs to move away from specialist clinics and into primary care. 41,42 Gender-affirming healthcare should be integrated into existing primary care services, as has been done with HIV care in South Africa. Primary care nurses are in a key position to ensure that TGD clients receive better care and experiences within healthcare facilities. 43 Delivery of HT by primary care providers using the IC model can be performed safely and effectively for adult clients, with specialist endocrinologist care needed only for complex cases. 44 Specialist involvement may also be of great value for an adolescent client; however, case-by-case decisions should be made within a multidisciplinary team context. 5 In addition, a sex-positive approach by the primary care provider is important. It recognises that each individual's sexuality is unique and multifaceted, and emphasises the importance of sexual pleasure, freedom and diversity. 45

Comprehensive care
Screening is part of prevention and providing comprehensive primary care. When caring for a TGD client, specific attention needs to be paid to the following areas:

Violence
Transgender and gender diverse persons experience a disproportionately high level of violence 39 and, therefore, a trauma-informed primary care approach is essential. 46 The World Health Organization (WHO) recommends the LIVES approach to violence (Listen, Enquire, Validate, Enhance safety and provide Support). 47 A client who has experienced sexual violence needs timely access to appropriate care, including post-exposure prophylaxis (PEP), sexually transmitted infection (STI) prevention and, if necessary, emergency contraception. 48

Mental health
Comprehensive care should include screening for mental health conditions, as well as consideration of the possible negative impact of gender dysphoria on the client's mental health, and the potential positive impact that genderaffirming treatment may have. 49,50 In a South African study, it was found that transgender adults had an incidence of anxiety of 25.9%, of substance use 21.0%, of eating disorders or psychotic disorders 2.3%, and a lifetime prevalence of mood disorder of 21.2%. 51 Assessment should include that of the client's existing support structure, and support and psychoeducational needs related to their care.
A TGD client should always be offered mental health support, 5,6 and continued support should be encouraged and facilitated, regardless of the client's mental health status. 29 A mental health condition is not a contra-indication to initiating HT, and it can be managed concurrently. 6 Referral to a MHP is required if there is a concern about decisionmaking capacity or if a mental health condition needs to be addressed. Whilst the presence of some mental health disorders (particularly those with manic or psychotic features) may have an impact on an individual's capacity to provide IC, a recent meta-review showed that most clients with a severe mental disorder made appropriate decisions regarding their healthcare. 52 An Australian study 30 revealed that general practitioners needed to refer only 8% of their TGD clients to a mental health professional prior to HT initiation and most of these clients had either schizophrenia or post-traumatic stress disorder (PTSD). Over half (56%) of TGD clients in this study had a mental health condition, such as depression, anxiety, attention-deficit-hyperactivitydisorder, autism-spectrum disorder or bipolar disorder; however, this did not have an impact on their capacity to consent to HT. 30

Substance use
Nearly half of transgender women (48%) and transgender men (49%) consume alcohol at hazardous, harmful or dependent levels. 39 These harmful drinking practices are associated with a lifetime experience of physical or sexual violence. 39 In addition, tobacco, alcohol and drug use can be used as coping mechanisms, 53 and tobacco use in combination with oestrogen therapy is associated with an increased risk for venous thromboembolism; 5 thus, screening is essential. A sensitive, client-centred approach within a harm reduction framework is recommended. 54

Fertility and contraception
Reliable contraception options must be explored in an assigned-female-at-birth (AFAB) client that has a uterus and ovaries, as pregnancy is still possible, even if the client is on testosterone. 55 The client's reproductive preferences should be thoroughly assessed, especially in the context of initiating HT. A transgender man who desires children may consider pregnancy 56 and chest feeding. 57 In a transgender woman who wishes to breastfeed, lactation can be induced by expression and medications (such as domperidone) with no adverse effects on the infant. 57,58

Cancer
Cancer screening is based on what anatomy (body part or organ) is present and whether the client meets the criteria for screening based on risk factors and/or symptoms. Relevant screening should be carried out regardless of HT use, 59 and there is no evidence for increased risk of cancer as a result of HT. 59 In a TGD client with cervical tissue, cervical screening, human papillomavirus (HPV) testing and HPV vaccination are essential. 60 In South Africa, cervical cancer ranks as the highest cause of cancer-related deaths in persons AFAB 61 , and screening should be performed regardless of the sexual orientation or comorbidities. 62 This can be performed with a Pap smear or a vaginal HPV swab test. A self-collected vaginal swab is an option for a client who is reluctant to have a vaginal examination. 63 In a TGD client with breast tissue, recommendations for breast cancer screening should be followed as for a cisgender person. 64 Prostate cancer has been documented in transgender women, although the prevalence is lower in transgender women than in cisgender men. 64 Screening should follow guidelines as for cisgender men; however, if a prostaticspecific antigen (PSA) test is carried out in a transgender woman with a low testosterone level, the upper limit of normal should be reduced to 1.0 ng/mL (rather than 2.0 ng/mL as in cisgender men). 65

Sexual health
In a client taking feminising HT, changes to libido and sexual response cycle are usually observed within 1-3 months of initiation of treatment. 66 In a client taking masculinising HT, an increase in sexual desire and activity is often reported 66 , and clitoral enlargement is likely to occur. 67 Vaginal atrophy may occur because of the hypoestrogenic effect that testosterone has on vaginal tissues 68 and can be ameliorated with lubricants.
A TGD client on HT may experience a shift in sexual orientation over time. 69

Sexually transmitted infections
Transgender and gender diverse clients are not a single category. Epidemiologic differences, such as the prevalence of gonorrhoea, require different responses for reducing infection and delivering appropriate sexual healthcare. 70 A client may engage in high-risk behaviour, and a detailed sexual history should aid screening and examination. Assumptions about the client's sexual orientation and behaviour should be avoided, and rather discussed in a non-judgmental way. It is also important to note that in African culture, the thought of sex as taboo limits the range of acceptable terms when discussing a sexual history. 71 The use of culturally respectful language can enable the reporting of truthful facts and minimise ambiguity or shame. 72 This can be performed jointly with visual aids or a bilingual lexicon when necessary. 73 Table 2 74 provides recommendations for how to take a sexual history and the isiNguni alternatives provided in the table acknowledge respect and personhood-principles, that are largely characterised and embraced by Southern African ethno-cultural populations.

HIV
Transgender and gender diverse persons are disproportionately burdened by HIV and have a greater risk of acquiring the virus, with the prevalence rate of HIV being 46% amongst transgender women in South Africa. 75 As such,  all TGD clients should be offered pre-exposure prophylaxis (PrEP). 76 PrEP has no impact on the concentration of oestradiol or testosterone levels and can be safely prescribed in a client on HT. 77 HIV testing and counselling services should address TGD-specific needs, and options, such as HIV self-screening, index testing and partner notification, should be offered. 59 Modern antiretroviral treatment (ART) and the use of an integrase inhibitor are recommended for a TGD client with HIV, as there are no contraindications to HT. 78 A dolutegravircontaining regimen is preferred over an efavirenz-containing regimen because it is generally better tolerated (fewer neuropsychiatric, hepatic and metabolic effects) and has a very high resistance barrier. 79 If the TGD client is on both spironolactone and cotrimoxazole, serum electrolytes and renal function need to be frequently monitored because of a possible drug interaction, which may lead to hyperkalaemia, severe illness and even death. 80 Particularly close attention should be paid to the client if they are elderly. 80 Transgender women with HIV are less likely to access HIV treatment or engage in care because of barriers, such as poverty, violence, stigma and unemployment. As such, there are lower rates of virologic suppression and higher HIVrelated mortality rates in this group. 81 Adherence to ART and PrEP should be emphasised. Social media platforms and other information communication technologies should be used to encourage retention in HIV care services. 82

Physical examination
It is important to note that a physical examination may cause the TGD client distress. Box 1 provides an affirming approach to a physical examination. 59

Non-medical gender-affirming practices
It is important to understand non-medical practices and to establish which strategies the client may use. These strategies are used by TGD individuals to modify their gender presentation, and include binding, tucking, padding and packing. 83,84 These strategies may alleviate gender dysphoria and can address the need to 'pass' as cisgender in a particular context. 84 It is important to understand associated risks and benefits, and provide the client with information on how to perform them safely.

Binding
Chest binding is used to flatten chest tissue. Specialised compression garments, bandages or duct tape may be used. Although this can be safely performed, risks may include back and shoulder pain, shortness of breath, and skin and soft tissue problems. Recommend 'off-days' from binding, encourage good skin hygiene, and advise the client to avoid elastic bandages, duct tape and plastic wraps. 85

Tucking
Tucking is used to present a flat pelvic area using a gaff (a specialised tight garment, often homemade), tape or tight briefs. 86 The testicles are pushed into the inguinal canal, and the penis is taped between the legs. 87 Although this can be safely carried out, risks may include testicular and penile pain, and skin problems such as a rash and itching. 86 Recommend tucking for shorter periods or less tight tucking, and good skin hygiene is encouraged. 59

Padding and packing
Padding involves the use of prosthetics or padding under the clothes to give the appearance of breasts and/or phenotypic female curves. Packing is the use of prosthetics or padding under the clothes to give the appearance of a penis and phenotypic male pelvic bulge. 83 Both padding and packing carry little to no health risk.

Psychosocial care
The term 'mental healthcare provider (MHP)' has been used, and refers to the broad spectrum of providers who may assist the client with their psychosocial needs. 5,89 These include clinical, counselling, educational and industrial psychologists; clinical, school and other social workers; psychiatrists; psychological and registered counsellors, and occupational therapists.

The role of the mental healthcare provider
A life-course approach alongside understanding the impact of minority stress, stigma and prejudice on the client's psychosocial well-being is recommended. 2,88,89 The concerns of the individual, as well as their broader socio-economiccultural context, should be addressed. The term 'mental healthcare provider (MHP)' has been used, which refers to the broad spectrum of providers who may assist the client with their psychosocial needs. 5,89 The MHP has many important roles in aiding gender-affirming care, as displayed in Table 3.

BOX 1:
An affirming approach to a physical examination.
• Adopt a trauma-informed approach, as many TGD clients find a physical examination uncomfortable or traumatic.
• Use correct pronouns and names. This is especially important in the context of a physical examination.
• Only conduct a genital examination if medically necessary.
• Explain to the client why the examination is necessary and what you will be doing.
• This can help to reduce anxiety. It is also an important part of obtaining informed consent.
• Be aware that the client may use alternative terminology for body parts -ask them which terms they would prefer you to use.
• Where possible, adapt procedures to make the client feel more comfortable (e.g. the client may be more comfortable with self-swabbing for HPV testing).

Children
A child can present as early as 2 or 3 years of age with persistent and consistent indicators of gender diversity. 5,94 The MHP needs to 'get to know' the TGD child, and gender incongruence must be determined together with the child and their caregiver(s). 5,6,94 Social transition is the recommended intervention for a TGD child, where it is their expressed need to do so 6 , and this can be facilitated by the MHP. 97

Adolescents
The prospect of puberty and developing secondary sexual characteristics in conflict with experienced gender identity is often daunting and even traumatic for a TGD adolescent. The MHP should work with the adolescent and their caregiver(s) and, if appropriate, facilitate access to puberty pausing treatment. 5,6,94,98,99

Adults
The MHP should offer an affirming and supportive space to enable TGD adults to come to an understanding and acceptance of their gender identity and its possible implications. 3,100 Any trauma experienced as a consequence of the client's gender identity should be addressed. A client who has begun transitioning within adulthood may require support with 'coming out' to their intimate partner(s), family, friends and work colleagues; and managing the resulting relational outcomes. 6,101,102 For an elderly client who may have specific challenges, such as an increased risk of isolation or loneliness, the MHP should help to identify sources of strength and resilience. 103 The MHP may need to assist in finding a safe and affirming living space with adequate medical and psychosocial care.

The meso and macro context
A MHP working with a TGD client (child, adolescent or adult) may need to engage with the client's broader family, learning institution or community to help to establish safe and affirming spaces for the client. This could include supportive counselling, psychoeducation, community education, resource development and linkage, offering a support space and advocacy actions. 3,5,6,94 6. Hormone therapy

Background
Gender-affirming hormones have been shown to be safe 104,105 and effective, 11 and were listed as essential medicines by the South African National Essential Medicine List Committee (NEMLC) in 2019, for tertiary level of care 106 . The goal of HT is to affirm the client's experienced gender. 17 In a non-binary client, it is particularly important to understand their desired outcome before deciding on treatment. 107 Provision of HT should be based on the principle of IC, rather than on the specific diagnostic criteria that have previously, and often harmfully, been applied. 11

Indications
In South Africa, the indications for accessing HT are as follows: • A desire to use HT.
• Persistent gender incongruence between one's experienced and assigned gender. • Capacity to make a fully informed decision and consent to treatment.

Role Description
Understand the complexities of 'Assessment' or 'Evaluation' The MHP needs to be cognisant that a mental health 'assessment' or 'evaluation' is particularly complex in relation to gender identity and gender-affirming healthcare in South Africa as it is a contentious concept that has historically been used to justify and maintain dominant ideology. 90 The TGD client's overall well-being and assessment or evaluation is a process of 'coming to know and understand' the client and their context. 91 An asset-based approach should be used, and the focus should be on establishing and maintaining a sufficient support structure, 4 thereby ensuring that the client understands the implications of gender-affirming medical interventions.
Aid diagnosis Recognise any mental health difficulties that the client may be suffering from and develop interventions that centre the client and do not pathologise their gender identity. Depathologisation is evident in the ICD-11, as it conceptualises 'gender incongruence' as a 'condition related to sexual health', 92   Agree on a mode of hormone administraƟon Establish client's desire to start hormone therapy. If no current desire or unsure, advise that they can rediscuss this decision at any Ɵme Establish individual goals and discuss hopes, expectaƟons, concerns Discuss ferƟlity and provide informaƟon on reproducƟve opƟons (For AMAB client, sperm cryopreservaƟon. For AFAB client, oocyte or embryo cryopreservaƟon) Discuss opƟons, possible side effects, risks and benefits (see Tables 4 and 7) Explain expected changes with Ɵmelines and reversibility (see Tables 5 and 7) Take history and screen for relevant condiƟons (See 3.2 Comprehensive care) Perform physical examinaƟon if needed (see Box 1) Request laboratory invesƟgaƟons (see Figure 1) Feminising therapy Start one oestrogen with or without one anƟandrogen (see Table 4)

Masculinising therapy
Start one testosterone (See Table 7) Ask about and manage side effects Discuss progress and manage expectaƟons Adjust dosing as needed Request laboratory invesƟgaƟons as needed (see Table 6) Ensure ongoing psychosocial support • If the client is an adolescent, consult with a multidisciplinary team to confirm gender incongruence and mental capacity to provide IC. 108 • If a significant medical or mental health concern is present, ensure that it is managed concurrently, without delaying HT. 30 • Gender dysphoria and real-life experience (a period of time in which a TGD individual has lived full-time in their identified gender role) are not prerequisites for the initiation or maintenance of HT. 6 Figure 1 shows a visual representation of the recommended process to follow when providing HT.

Feminising therapy
The aim of therapy is to promote the development of feminising sexual characteristics and to suppress the masculinising effects of endogenous testosterone. 109 The cornerstone of treatment is administration of exogenous oestrogen. The addition of an androgen receptor antagonist may be required to achieve full suppression of testosterone 110 ; however, recent evidence suggests that this may not be essential to reduce testosterone levels to cisgender female ranges, as was previously thought. 111 For conditions that may be exacerbated by oestrogen administration, such as oestrogen-sensitive malignancies, coronary artery disease and cerebrovascular disease, careful evaluation should be done prior to HT initiation 66 and HT individualised. In a client with a history of venous thromboembolism (VTE), transdermal oestrogen may be considered after an IC discussion. 59,112  Feminising treatment options are shown in Table 4, and effects and reversibility of treatment are shown in Table 5. 126 Baseline screening is recommended prior to HT treatment, as shown in Figure 2. 127 A client's experience on treatment should be the primary guiding factor in dose titration and maintenance, and treatment may still be provided in resource-constrained settings where laboratory measurement of hormonal levels is not available. However, when these investigations are accessible, they can provide helpful guidance in optimising the dose. Recommended laboratory monitoring is shown in Table 6. 59

Masculinising therapy
The goal of masculinising therapy is to promote the development of testosterone-induced secondary sexual characteristics. 128 Suppression of oestrogen and ovulation will almost always occur 108 and, thus, oestrogen antagonists are not required.
Exogenous testosterone can be administered by intramuscular or subcutaneous injection or as a topical transdermal preparation. Oral testosterone should be avoided as it is hepatotoxic. 67 A client with severe hypertension, sleep apnoea or untreated polycythaemia (haematocrit above 55%) requires management prior to treatment initiation, as these conditions may be exacerbated by testosterone. 66 Testosterone treatment options are shown in Table 7 66,129 , whilst effects and reversibility of treatment are shown in Table 8. 66,109 Baseline screening and monitoring are recommended, as indicated in Figure 2 and Table 6, respectively.

Adolescents
Whilst HT is not required for prepubertal TGD children, pubertal suppression to halt the progression of physical changes may significantly reduce distress in a TGD adolescent, 94,108 which, in turn, has been shown to improve mental health conditions and decrease suicidality. 130 Puberty can be suppressed with gonadotrophin-releasing hormone agonists (GnRHa) once Tanner Stage 2 of puberty has been reached. 94 Gonadotrophin-releasing hormone agonists available in South Africa include leuprolide and goserelin, both of which are administered every 12 weeks via intramuscular or subcutaneous injection. 131 It is recommended that a paediatric endocrinologist oversees this care, 5,108 and that fertility preservation is discussed prior to HT initiation. 132 The timing of HT initiation should be individualised, and should consider family support, likely time on GnRHa, potential impacts on height, risks of delaying HT and the adolescent's ability to consent. 94 The inclusion of an MHP and, ideally, the parents or legal guardians are recommended when deciding on the appropriateness of HT. 5

Mature clients
Hormone therapy is indicated as a long term treatment, as some body changes may reverse if it is stopped. 59 There is no age recommendation for the reduction or termination of HT, and individual cardiovascular risk in the mature TGD client needs to be considered and discussed with the client. 59

Preoperative considerations
It is important to note that there is diversity in the surgery requested by TGD clients. 133 A client may desire for chest or facial or genital surgery only, or a combination of these. A non-binary client's request for surgery should be specifically individualised. 134 Tables 9 and 10 show, respectively, the available feminising and masculinising surgical options. Hormone therapy is usually recommended prior to surgery; however, a client may be unable to or prefer not to take HT prior to surgery. 6 In South Africa, a documented process of thorough IC is essential prior to surgery.

Peri-surgical care
Post-surgical care is vital to recovery, and should include psychological care and physiotherapy. It is important to note that the continuity of gender-affirming care does not end with the surgical procedure(s), and ongoing support should be provided. The TGD community can play a significant role in perioperative care, both through peer and organisational support groups. 140 Satisfaction following surgery is usually high, with less gender dysphoria, reduced psychological distress and better integration into society. 141

Care facilities
Providing a safe, welcoming, and culturally appropriate healthcare environment is essential to ensure that a TGD client not only seeks care but also returns for follow-up. 59 The following are recommendations for care facilities, including healthcare facilities, 142,143 old-age homes 103 and shelters 144 : • Ensure that staff are trained to care for a TGD client, and that anti-discrimination and anti-harassment policies are in place. • Limit language as a barrier by ensuring that there is staff competency to present information in more than one of South Africa's 11 official languages and, if required, basic South African sign language. • Ensure that the client's gender identity and treatment information are kept confidential and protected under the Protection of Personal Information Act (POPIA). • Ensure registration records and intake forms reflect the client's name-in-use, legal name and surname (if relevant and in consultation with the client), pronouns and gender. • Practise discretion with billing information in terms of differentiating between the client's legal name and namein-use, and consult with the client directly to avoid any breaches of confidentiality. • Respect a person's name and pronouns, regardless of the appearance, history or sex assigned at birth. • Assign the person to a bed or room or ward based on their self-identified gender. • Ensure the client's equal and fair access to bathroom facilities that are aligned with their self-identified gender (including fully private, non-binary or gender-neutral bathrooms). • Ensure that the client has access to personal items that facilitate their gender expression (this may include items, such as makeup and shaving equipment, and items used to bind, pack or tuck). • Ensure residents in shelters are able to choose their clothing, residential allocation (e.g. in single-gender settings) 144 and are protected from gender-identity discrimination. 103

Correctional facilities
The following are specific recommendations for TGD offenders: • Ensure that all correctional staff are trained on gender identity and diversity, and that all in-house health providers are trained in GAHC. 145 • Ensure safe and secure detention and incarceration, with appropriate section placement to reduce victimisation. 146 • Assign the offender to a single cell, if this is their preference, but recognise that this protective placement might in itself result in victimisation. 147 • Facilitate access to HT. 148 • Ensure that the offender has access to sexual healthcare (provision of condoms, PEP and PrEP), given their increased exposure to HIV and STIs. 146

Work facilities
Inclusion begins before a TGD staff member's social transition within the workplace. Collaboration between leadership and human resources is needed for the implementation of clear guidance to support TGD staff. 149 Healthcare providers can play an advisory role in needs assessment, intervention design and implementation, and policy development and employee benefits.

Educational facilities
In accordance with South African legislation, all schools, whether private or public, mixed or single gender, must ensure an inclusive, non-discriminatory and diversityaffirming environment. 150,151,152 This supports basic human rights, actualisation of potential, human dignity, equality, right to education, protection from physical and emotional harm, and is in the best interest of the learners. Healthcare providers can assist schools with the development of relevant policies and guidelines, as well as staff sensitisation. 3

Voice and communication
It is helpful to understand how sex and gender influence voice and communication, and that a speech-language therapist (SLT) can play an important role in this regard. 6 Voice and communication are often closely connected to gender identity or expression, and the TGD client may want to sound more feminine, more masculine or gender neutral.
Masculinising HT can contribute to a desired voice change but may not be sufficient to achieve the client's goals. Feminising HT is unlikely to result in a desired voice change. The TGD client, therefore, may benefit from referral to a qualified SLT with experience in providing gender-affirming care. 6 The main strategy for voice care is related to the alteration of one's speaking fundamental frequency, intonation and resonance. 153,154 The SLT should perform a voice and communication assessment, which includes a quality of life measure, 155,156 and can provide both voice and communication interventions, as shown in Table 11. It is important to acknowledge South Africa's multilingual communication landscape, and that communication requires an individualised approach and specialist intervention. Table 12 shows important key terms used within the field of GAHC.

Ethical consideration
To the fullest extent permitted by law, the Southern African HIV Clinicians Society (SAHCS) and the authors of this study cannot be held liable for any aspect of healthcare administered using this information or any other use, including any use that is not in accordance with any guidelines or (mis-)use. Specific recommendations provided here are intended only as a guide to clinical management based on expert consensus and best current evidence at the date of first publication. Management decisions for clients should be made by their responsible clinicians, with due consideration for individual circumstances and various contexts. The information provided in this document should not be considered as a substitute for such professional judgement. The most current version of this document should always be consulted.

Funding information
The authors received no financial support for the research, authorship or publication of this article.

Data availability
Data sharing is not applicable to this article, as no new data were created or analysed in this study.

Disclaimer
This research article followed all ethical standards for research without any direct contact with human or animal subjects.

Term Explanation
Cisgender Abbreviated as 'cis', describes a person whose gender identity and expression match their sex assigned at birth. 3 Gender 'An institutionalised system of social practices for constituting people as two significantly different categories, men and women; and organising social relations of inequality on the basis of that difference'. 158 Gender is based on social norms and expectations. In many cultures, people are divided into a gender binary of either men or women; however, there are also cultures that recognise other genders, sometimes as a third-gender category, or as a range of non-binary identities, for example genderqueer, gender fluid, and also as bigender or agender. Most societies have a history of systemic gender inequality, with men occupying a privileged position and women being subjected to socio-economic disadvantage, discrimination and violence. Because of colonisation, the binary Western perspective has been entrenched within our society.
Gender dysphoria The psychological and/or physical distress caused by the incongruence between sex assigned at birth and gender identity. Not all TGD individuals experience gender dysphoria; however it can be debilitating for some. Although gender dysphoria is a medical diagnostic classification in the Diagnostic and Statistical Manual-5 (DSM-5). 93 TGD individuals' experiences of it are diverse and may affect their lives in various ways.
Gender expression Aspects of a person's physical appearance and behaviour, which is defined culturally or socially to be either masculine or feminine. Every society has its own normative assumptions and prescriptions about how women and men should feel, dress, act and work. Gender expression can also be fluid or non-conforming. 159 Gender identity Defined by the Yogyakarta principles (South Africa is a signatory to these principles) as 'each person's deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal sense of the body (which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical or other means) and other expressions of gender, including dress, speech and mannerisms'. 9 Cis-heteronormativity Refers to the hierarchical system of power, prejudice and discrimination, in which cisgender and heterosexual individuals are privileged above sexual and gender diverse (or perceived sexual and gender diverse) persons.

Intersex
Refers to persons born with sex characteristics, such as chromosomes, gonads and genitals, which do not fit typical binary notions of male or female bodies. Intersex is an umbrella term used to describe a wide range of natural bodily variations. 160 Some people with intersex traits self-identify as intersex, and some do not. Some prefer the term Differences of Sex Development or Diversity of Sex Development (DSD). The medical term Disorder of Sex Development is often considered derogatory by intersex persons as difference or diversity should not automatically be pathologised.
LGBTQIA+ An umbrella term for communities who, for different reasons, have a shared experience of marginalisation and discrimination in society, and who have shared goals of improving access to human rights and basic freedoms. L stands for lesbian, G for gay, B for bisexual, T for transgender, Q for queer or questioning, I for intersex, A for asexual or agender, and + indicates developing language and the inclusion of other diverse gender identities and sexual orientations.

Misgendering
Intentionally or unintentionally using an inaccurate pronoun or description in a way that undermines a person's gender identity. Similarly, deadnaming (necronym) refers to using a TGD person's previous given name, despite them having changed their name, or asked to be addressed by a name that reflects their gender identity.
Non-binary A range of gender identities that do not fall into the traditional binary categories of male or female. It is important to recognise that this gender binary does not describe the identity of many people. People with non-binary gender identities may identify as gender fluid, gender diverse, agender, genderqueer, gender non-conforming, transmasculine, transfeminine or various other non-binary identities.

Sex
A complex interplay of multiple physical characteristics (including hormones, internal reproductive organs, gonadal tissue, genitalia and chromosomes) that cannot be categorised into a binary of male or female. When a child is born, they are usually assigned as either female child (assigned female at birth [AFAB]) or male child (assigned male at birth [AMAB]) based solely on the observed external genitalia at birth. This does not account for intersex individuals or for diversity of sex development (DSD), which is problematic.
Sexual orientation Describes who one is intimately attracted to, and with whom one has emotional or sexual relationships and the sexuality one may identify with. Sexual orientation is not the same as gender identity. Gender identity refers to a person's experience of their own gender, and sexual orientation refers to their attraction to others. A person's gender identity does not in any way predict their sexual orientation.

Transgender
A term that describes a person who does not identify (wholly or partially) with their sex assigned at birth. A transgender woman is someone who was assigned male at birth (AMAB) but who identifies as a woman. The previous term MTF (male-to-female) is no longer considered widely acceptable or accurate. A transgender man is someone who was AFAB but who identifies as a man. The previous term FTM (female-to-male) is no longer considered widely acceptable or accurate.

Transphobia
An irrational and systemic hostility towards people who are transgender, gender diverse, or who otherwise do not fall into traditional gender categories and norms.
TGD, transgender and gender diverse. therapy The informed consent forms contained herein are included as examples of what such a document might look like, and the kind of information it may contain. These are not intended to be used 'as is' but should rather serve as a template or guideline to practitioners to help them craft their own informed consent forms, specific to their practices.
Many TGD clients choose to seek gender-affirming care in the form of hormone therapy (HT). The decision to start on HT rests with you, the client, and not with your healthcare provider. The informed consent model of treatment provides you agency over this decision -it is the role of your doctor to support and guide you through this process safely and effectively.
You may have read up, or heard from other TGD people, about HT. Some of the information that you may have come across could potentially be out of date or inaccurate.
If you have any questions or concerns at any time, you should always feel free to raise these concerns with your healthcare provider.
Please remember that every client is unique and will respond differently to medication, and that one client's treatment programme might differ substantially from another because of a variety of physiological and medical factors. Try not to compare the treatment you are receiving with that of anyone else -your journey is your own. If you have concerns about the efficacy of your treatment, make a point to discuss this with your provider at your next appointment.
Before starting on HT, there are a few points that are worth considering. This informed consent document will draw your attention to some of these points, as well as outline the expected effects, side effects and risks that are associated with HT to make sure that you have all the information you need to make the best decision about your body and your health.

The role of psychotherapy in transgender and gender diverse clients
Visiting a psychologist is not a requirement for initiating HT. Whilst previously some healthcare providers required a letter of diagnosis or referral, this is no longer necessary under international best practice.
Your doctor will ask you some questions to determine that you have a good support structure as you move forward. This is not because going on HT itself necessitates this but rather because for many clients of TGD experience, navigating the world is already difficult, and HT, although often resulting in many positive and beneficial changes, can also lead to some emotional lability. A solid support structure looks different for everyone; however, this may include friends, families, support groups, therapists or counsellors. Your doctor might suggest or offer you referrals to support groups and therapists, if you indicate that you might benefit from these.

The role of endocrinologists and other specialists
Hormone therapy does not need to be prescribed or monitored by an endocrinologist. Prescribing HT is well within the realm of a suitably skilled general practitioner (GP) or family physician. Not all GPs, nor all endocrinologists, have experience in managing gender-affirming HT, and the expertise of the clinician should be the guiding factor in determining who prescribes and monitors your HT.
You may benefit from visiting other allied healthcare professionals, such as speech therapists, or from medical specialists, such as plastic surgeons. Not every TGD client will necessarily want to pursue these options, and you should discuss your individual goals with your prescribing doctor.

Home affairs and gender marker
If you wish to update your gender marker on your birth certificate and ID document, the Department of Home Affairs requires two letters from healthcare professionals, which state that you have undergone medical or surgical gender reassignment. Either of these is sufficient; you do not need to have had surgery to update your gender marker. Unfortunately, at present, gender markers in South Africa are binary; thus, an ID document can reflect either female or male gender; there http://www.sajhivmed.org.za Open Access Your doctor will discuss with you the various options for HT that are available and help you to decide which form of treatment is best for you.

Costs of hormone therapy
It is important to remember that not only do different clients have different needs in accessing HT but also that prices for medication may vary between different pharmacies, and that these prices may fluctuate over time. The majority of clients can expect to spend approximately R300-R500 per month on HT. This does not include monitoring blood tests or doctor's visits.

Changes that occur when using hormone therapy
The changes you will experience on HT often take some time to fully develop. Some of these changes are reversible, and will disappear should you discontinue HT. Others are irreversible and will persist even if you stop taking your hormones.
The timeline for these changes to begin is variable; however, most of them will only reach their maximum degree after 3-5 years on HT.

Reversible changes
• loss of muscle mass and decreased strength • changes in body fat distribution, possibly associated with weight gain (increased fat deposition in breasts, buttocks, hips and thighs) • softer and thinner skin • reduced acne • lighter and thinner body and facial hair • cessation of male-pattern balding, possible scalp hair regrowth • changes in sex drive (usually a decrease initially, followed by an increase together with a change in sexual response cycle) • changes in the strength and frequency of erections, and changes in the amount and consistency of ejaculate • changes in mood and emotional response.

Irreversible changes
• breast development; whilst the size of breast tissue may fluctuate, HT will cause permanent development of breast structures, which will remain even if HT is withdrawn • testicular atrophy • infertility • changes in bone density.

Limitations of hormone therapy
It is important to understand that there are certain features that HT cannot alter, which include the following: • presence of facial hair -although HT may make the hair thinner, or cause it go grow more slowly, HT will not eliminate facial hair • pitch of the voice • bone structure of the face • presence of thyroid cartilage (Adam's apple). Patches need to be applied and cared for correctly May cause skin reactions because of adhesive. †, Taking an oestrogen tablet sublingually involves holding the tablet in the mouth -either under the tongue, inside the cheek, or between the lips and teeth, whilst the tablet dissolves. After dissolving, the residue must be held in the mouth for a further 30 min to fully absorb, and any remnants need to be spat out and the mouth thoroughly rinsed. It is important not to swallow at all during this time, as any swallowed medication will move through the digestive tract and carry a higher risk of adverse events.

Important risks associated with hormone therapy
As with any medication, HT carries with it certain risks. Some of these risks can be mitigated or reduced by lifestyle factors, whilst others are independent risks that cannot be altered. It is important to be fully aware of the risks associated with HT before starting your treatment.
Blood clots are the most prominent risk factor associated with feminising HT. A blood clot can lead to DVT, pulmonary embolism (a blood clot in the lungs), heart attacks or strokes. These conditions may be severely debilitating or even fatal: Some clients will experience a reduction in their blood pressure and improvements in their cholesterol levels on HT. This is not a guarantee and is not a replacement for positive lifestyle changes.

Fertility
Although not all clients become infertile on HT, and some might regain fertility if they stop HT, many may become irreversibly infertile. Hormone therapy is not a replacement for effective and responsible contraceptive use.
All clients considering starting on HT should consider using a Cryobank to preserve genetic material, in case they wish to conceive genetically related children at a later stage. Even if this is not a priority for you at this stage in your life, please consider the possibility that your perspectives might change with time, and that it is ideal to store material before starting HT rather than trying to regain fertility once you are already on hormone treatment.
Your doctor can refer you to facilities that can assist in cryopreservation.

Monitoring and follow up
Your doctor will advise and guide you in monitoring your safety while you are on HT. Usually, this will involve regular checkups and physical examinations, as well as certain blood tests.
At the outset, it is not uncommon for these evaluations to be performed monthly, whilst you are still achieving the correct hormonal balance for you. Later, once you are stable on treatment, these intervals might be extended to 6-monthly, or perhaps even annually. This schedule is different for every client.
If you decide to stop your HT, you should discuss this decision with your doctor. It can be dangerous to abruptly withdraw HT without adequate medical supervision.

More information
Please remember that you can discuss any questions or concerns with your doctor at any time.

Informed consent for feminising hormone treatment
I confirm that I have read and understand the information above.
I confirm that my doctor has told me about the effects of feminising hormone treatment, including the more common or serious risks and side effects as mentioned above.
I understand that some of these effects may be permanent.
I understand that as part of my treatment plan, I shall take my medication as prescribed and have check-ups, including blood tests as required.
My doctor has offered me adequate opportunity to ask any questions that I have regarding feminising hormone therapy.
I hereby agree that my doctor starts/continues treating me with feminising hormone therapy. Your doctor will discuss with you the various options for HT that are available and help you to decide which form of treatment is best for you.

Additional medications
For clients who wish to achieve suppression of menstruation, but have not performed so on testosterone alone, progesterone may be added.
Some clients will use topical minoxidil in order to achieve fuller facial hair growth.

Costs of hormone therapy
It is important to remember that not only do different clients have different needs in accessing HT but also that prices for medication may vary between different pharmacies, and that these prices may fluctuate over time. The majority of clients can expect to spend between R200 and R600 per month on HT. This does not include monitoring blood tests or doctor's visits.

Changes that occur when using hormone therapy
The changes you will experience on HT often take some time to fully develop. Some of these changes are reversible and will disappear should you discontinue HT. Others are irreversible and will persist even if you stop taking your hormones.
The timeline for these changes to begin is variable; however, most of them will only reach their maximum degree after 3-5 years on HT.

Reversible changes
• gain of muscle mass and increased strength • changes in body fat distribution, possibly associated with weight gain (increased fat deposition in the abdomen, and decreased fat in breasts, buttocks and thighs) • coarser and thicker skin • increased acne • coarser and thicker body hair • increased red blood cell count • increase in sex drive • changes in mood and emotional response (often initially an increase in irritability, amongst other emotions) • cessation of menses and ovulation, and dryness of the genital tissues.

Irreversible changes
• hair loss or male pattern baldness may occur • facial hair growth • deepening of the voice • enlargement of the clitoris • infertility.

Limitations of hormone therapy
It is important to understand that there are certain features that HT cannot alter, which include the following: • presence of breast tissue -HT can reduce fat deposition in the breasts and make them smaller; however, it will not result in a loss of actual breast tissue • bone structure -HT will not change the structure of your pelvis or make you grow taller

Important risks associated with hormone therapy
As with any medication, HT carries with it certain risks. Some of these risks can be mitigated or reduced by lifestyle factors, whilst others are independent risks that cannot be altered.
It is important to be fully aware of the risks associated with HT before making the decision to start your treatment: • high cholesterol or blood fats • increased red blood cell count • high blood pressure.
All of the above can lead to or worsen cardiovascular disease, or lead to strokes. These conditions can be life threatening.

Liver disease
Psychiatric symptoms include mood disturbances, anxiety or psychosis, especially if there are pre-existing mental health conditions. If you have been diagnosed with a mental health condition and/or use psychiatric medication, you need to discuss the starting of HT with your doctor. The use of hormones can interact with various medications and may have an impact on your mental health conditions. Some of the risks mentioned are modified by other factors. Notably, cardiovascular and clot risks are worse in clients who • smoke • use alcohol • have pre-existing medical conditions, such as diabetes, high blood pressure and high cholesterol.

Fertility
Although not all clients become infertile on HT, and some might regain fertility if they stop HT, many may become irreversibly infertile. Hormone therapy is not a replacement for effective and responsible contraceptive use.
All clients considering starting on HT should consider using a Cryobank to preserve their genetic material, in case they wish to conceive genetically related children at a later stage. Even if this is not a priority for you at this stage in your life, please consider the possibility that your perspectives might change with time, and that it is ideal to store genetic material before starting with HT rather than trying to regain fertility once you are already on HT.
Your doctor can refer you to facilities that can aid in cryopreservation.

Monitoring and follow-up
Your doctor will advise and guide you in monitoring your safety whilst you are on HT. Usually, this will involve regular check-ups and physical examinations, as well as certain blood tests.
At the outset, it is not uncommon for these evaluations to be performed monthly, whilst you are still achieving the correct hormonal balance for you. Later, once you are stable on treatment, these intervals might be extended to 6-monthly, or perhaps even annually. This schedule is different for every client.
If you decide to stop your HT, you should discuss this decision with your doctor. It can be dangerous to abruptly withdraw HT without adequate medical supervision.

More information
Please remember that you can discuss any questions or concerns with your doctor at any time.