The review sought to:

In doing so, this rapid review aims to support healthcare providers, policymakers, educators, civil society, and families in delivering care that is evidence-informed, developmentally appropriate, and aligned with the rights and dignity of TGD youth.

Included publications:

Excluded publications:

Given the diversity of interventions and outcomes, precise Population-Intervention-Comparator-Outcome-Time (PICOT) criteria could not be predefined. However, inclusion criteria were aligned as closely as possible to these frameworks, as shown in Table 1.⁶⁵

All empirically assessed psychosocial and health outcomes and all empirical study designs (quantitative, qualitative, and mixed methods) were eligible. Meta-analysis was not feasible because of extreme heterogeneity in populations, interventions, and outcome measures; findings are therefore synthesised narratively. The full technical report, available at https://pathsa.org.za/resources/rapid-review-2025, adheres to Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) 2020 reporting standards,⁶⁶ with transparently reported streamlining adaptations consistent with interim published guidance for rapid reviews.⁶⁴

Searches were conducted on 26 November 2024, 04 December 2024, and 14 August 2025 across 12 databases via EBSCOhost (University of Pretoria), supplemented by searches of ClinicalTrials.gov and the International Standard Randomised Controlled Trial Number (ISRCTN) registry, and targeted searches for recent systematic reviews. Search date limits were set to capture records indexed between 01 January 2021 and 31 December 2025, thereby including articles indexed online ahead of their recorded publication dates. The search strategy combined [any term for trans and gender diverse identity] AND [any term for youth under 18] AND [any term for interventions related to gender identity]. Full search strings are provided in the technical report. No language restrictions were placed on the search results. Titles and abstracts of non-English sources were screened based on publisher-provided English translations whenever available and supported by Google Translate as needed.

Two custom Airtable-based tools were used to extract data from primary studies and systematic reviews, capturing study characteristics, populations, interventions, outcomes, and key results. Data extraction for non-English sources was based on publisher-provided English translations in all but one case, where the full text of a Spanish-language article was translated using Google Translate. The machine-translated text was reviewed alongside the original article, with key passages verified by a Spanish-speaking research assistant. Formal de novo risk-of-bias or certainty grading across all individual studies was not undertaken; instead, where available, methodological appraisals and certainty assessments reported in included systematic reviews were used qualitatively to inform interpretation.

Data extraction from full-text sources was conducted by authors KL Dunkle and Ingrid Lynch. Two large language models (LLMs), ChatGPT and Perplexity, were used in a limited, supportive capacity. A structured data-extraction prompt was applied to individual PDFs to generate draft plain-text data extraction elements aligned with predefined Airtable fields. These drafts were line-checked against the original sources, corrected where necessary, and manually entered the extraction database. LLMs were instructed to flag missing, ambiguous, or uncertain data elements for targeted human review, and all errors and gaps were resolved by the human reviewers using the original reports.

LLMs were also used on an ad hoc basis to cross-check draft narrative descriptions of results against spreadsheets of the extracted data and source PDFs, supporting identification of potential omissions or internal inconsistencies for human correction. LLMs were not used for study screening, inclusion–exclusion decisions, formal analysis, recommendation development, conflict-of-interest statements, or contextual framing. All LLM-generated outputs were treated as provisional drafts and were reviewed, verified, and rewritten by the human author team prior to inclusion.

Narrative syntheses drew on structured Airtable data extractions, with attention to intervention type, outcome measures, study design, sample characteristics, follow-up duration, and any certainty ratings reported in prior reviews. Findings were organised across five domains of care: psychosocial, endocrine, surgical, non-medical gender-affirming practices, and policy and legal interventions. Domain leads verified that narrative summaries accurately reflected underlying data and appropriately characterised any methodological uncertainty. The synthesis prioritised practice-relevant findings and patterns in relation to benefits, harms, and equity and access considerations, while explicitly noting where evidence was sparse, methodologically weak, or inconsistent.

Three cross-cutting interpretive lenses guided synthesis:

Finally, to strengthen practice relevance, synthesised findings were assessed against the 2021 SAHCS GAHC Guideline.⁸ For each intervention domain, evidence was considered in terms of direction of effect, consistency, methodological quality, follow-up duration, and relevance to the South African context. Implications for existing Guideline recommendations were classified as:

These classifications were reviewed iteratively by the full author team, with reference to the synthesised evidence, to ensure analytic coherence and contextual appropriateness.

We identified 53 primary studies,^{68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120} 12 academic systematic reviews,^{10,11,13,15,19,20,22,23,24,31,36,121} and three grey-literature systematic reviews^37,38,39 examining psychosocial aspects of care for TGD children and adolescents. The full list of primary studies is provided in Table S-D in the Online Supplementary Appendix. The evidence base is methodologically heterogeneous and dominated by observational and qualitative designs, with the majority comprising cross-sectional surveys or retrospective clinic-based analyses.^{72,76,77,85,91,92,93,94,96,99,100,102,103,104,106,108,109,112,113,117,118,119,120} A substantial proportion of studies used qualitative or mixed methods designs, drawing on interviews with young people, caregivers, families, or clinicians to explore experiences of support, identity development, barriers to access, and care processes.^{70,79,80,84,87,88,90,93,98,101,105,110,111,114}

Affirming psychosocial practices such as supporting a young person’s gender expression,^{19,69,83,89,91,93,94,115,117} strengthening family and peer connectedness,^{10,22,36,76,81,85,92,104,106,109} creating safer school environments,^{11,36,86,93,95,100,102,108,113,118,121} and providing tailored psychological or digital interventions^{37,68,71,73,74,75,79,120} are associated with reductions in depression, anxiety, and suicidality, as well as improvements in resilience, sense of belonging, school participation, and daily functioning. However, access to affirming support is not evenly distributed, with nonbinary youth and racially marginalised TGD youth reporting lower levels of gender affirmation and support across social and care contexts.^91,104 No included study or systematic review reported harms attributable to affirming psychosocial care.

By contrast, non-standard or pathologising practices – including identity-change efforts, enforced or non-clinical delays in social affirmation, or withholding affirmation – which fall outside recognised standards of psychosocial care, are consistently associated with adverse outcomes, including heightened distress, self-harm, suicidality, and deteriorating family relationships.^{38,77,87,94,111}

Most studies are cross-sectional, self-reported, and concentrated in high-income settings, with relatively few longitudinal or experimental designs; these factors limit certainty of evidence in individual reports. Nonetheless, the consistency of findings across survey-based, qualitative, and mixed-methods studies, alongside diverse care contexts and outcome measures, supports psychosocial affirmation as both safe and beneficial. Taken together, findings underscore that mental health outcomes are shaped by family, school, and community contexts, and highlight the importance of supporting children and adolescents who face inconsistent or unsupportive family environments. Findings also point to the need to support youth facing overlapping social and structural stressors, and to ensure equitable access to affirming psychosocial support across diverse social, educational, and community settings.

Overall, the evidence on psychosocial interventions and support for TGD youth is consistent with the 2021 SAHCS GAHC Guideline recommendations. Table 2 summarises key implications for guideline development, mapping synthesised evidence against existing guidance and highlighting areas of support and refinement.

We identified 23 primary studies,^{122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144} three academic reviews,^26,28,33 and one grey-literature report³⁹ with focused evaluation of puberty-pausing medication; 28 primary studies,^{145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170,171,172} and two academic reviews^25,32 with focused evaluation of GAHT; and 53 primary studies,^{78,87,88,153,154,155,156,173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190,191,192,193,194,195,196,197,198,199,200,201,202,203,204,205,206,207,208,209,210,211,212,213,214,215,216,217,218,219,220} 11 academic reviews^{9,11,12,16,17,18,21,27,29,34,35} and three grey-literature reports^37,38,40 with joint or overlapping evaluation of puberty pausers and GAHT (see Online Supplementary Appendix: Table S-E, Table S-F and Table S-G).

The literature shows a consistent pattern: endocrine interventions for TGD adolescents generally achieve their intended physiological effects^{25,32,33,37,38,40,124,126,203}; adverse events are typically anticipated, predominantly mild, and manageable under routine monitoring in specialist care, with specific adverse events described in relation to individual interventions below.^{123,124,131,146,150,173} Mental-health outcomes are broadly stable or improved.^{122,127,142,166,209} Although the evidence base is methodologically constrained and concentrated in high-income clinical settings, available data provide a short- to medium-term picture of effectiveness and safety.^{9,21,27,34,35}

Puberty-pausing medication reliably halts unwanted pubertal development,^{39,124,126,130,136,142,143} and GAHT induces expected masculinising or feminising changes.^{25,32,37,38,150} Endocrine and metabolic parameters typically remain within clinically acceptable ranges under supervised care.^{124,140,150,210} Bone-density reductions during pubertal suppression are common and well-described,^{125,132,137,195} and typically show partial or substantial recovery following subsequent GAHT or endogenous puberty, especially when progression to hormones is timely and aligned with clinical indicators.^{125,175,197,203,207,213} Serious adverse events are rare across endocrine pathways, with no consistent pattern of irreversible harm.^{149,173,204,216,220}

Mental-health outcomes are heterogeneous at the individual level, yet broadly stable-to-favourable across cohorts. Adolescents who access puberty suppression and/or GAHT generally show reductions in depressive symptoms and suicidality, alongside improved appearance congruence and functioning, compared with their own baseline and with peers who want but cannot access treatment.^{160,161,164,166,181,194,209} Worsening mental-health trajectories are more consistently associated with delayed or restricted access to care than with endocrine treatment,^166,209 with GAHT linked to lower risks of suicidality-related emergency or inpatient care and to fewer mental-health diagnoses and psychiatric hospitalisations following treatment initiation.^192,200

Longitudinal data indicate high continuation into adulthood and very low reported regret among adolescents who commence endocrine care.^{153,154,156,212,213} Where discontinuation occurs, it is very often linked to external or structural factors (such as access barriers, service disruptions, costs, insurance denials, family stressors, or bullying), completion of desired physical changes, or evolving identity-related needs, rather than to treatment-related side effects or regret.^{16,153,154,163,184}

Although menstrual suppression as gender-affirming care is not explicitly addressed in the 2021 SAHCS GAHC Guideline, review of evidence from five primary sources^{221,222,223,224,225} (Online Supplementary Appendix: Table S-H) suggests that it is a safe, effective, and highly valued component of care for TGD adolescents who menstruate. Reported outcomes include high rates of amenorrhoea, reduced pain and menstrual-related dysphoria, and high overall satisfaction, with mild and infrequent adverse events.^{221,222,223,224,225}

Fertility preservation was addressed in 16 primary sources^{226,227,228,229,230,231,232,233,234,235,236,237,238,239,240,241} (Online Supplementary Appendix: Table S-I), one academic systematic review,³⁰ and two grey-literature reviews.^37,38 Although gamete preservation appears feasible and generally safe for adolescents, interest is typically low, and accessibility for those who are interested is substantially constrained by cost, procedural dysphoria, and timing of referral.^{37,38,226,227,229,230,231,232,233,234,235,236,237,238,239,240,241} These factors highlight the importance of early, developmentally appropriate, and iterative fertility counselling.

Overall, the evidence aligns with the 2021 SAHCS GAHC Guideline recommendations. Table 3 and Table 4 summarise key implications for guideline development for puberty pausing and GAHT, respectively, mapping synthesised evidence against existing recommendations. Table 5 outlines implications for future guideline development related to menstrual suppression.

We identified 10 primary studies reporting outcomes of gender-affirming surgery in adolescents,^{242,243,244,245,246,247,248,249,250,251} and 15 primary studies in which surgery was examined within broader gender-affirming care trajectories that also included endocrine and/or psychosocial care^{163,184,196,213,228,252,253,254,255,256,257,258,259,260,261} (Online Supplementary Appendix: Table S-J1 and Table S-J2). Two grey-literature systematic reviews assessed surgical outcomes in youth.^37,38

Evidence for patients under age 18 is limited in volume but highly consistent, focusing almost entirely on masculinising chest reconstruction, which is the only gender-affirming surgery routinely accessed by adolescents.^{242,243,244,245,246,247,248,249,250,251} A very small number of other procedures (e.g. hysterectomy, vaginectomy, facial feminisation) are reported in United States national registry data, but are vanishingly rare in under-18s.²⁴⁵ Within multidisciplinary programmes, masculinising chest surgery shows very low complication and revision rates, with safety profiles favourably comparable to those observed in adults or cisgender youth undergoing analogous chest procedures.^{242,244,245,249,250}

Psychosocial outcomes of gender-affirming surgery are consistently positive in the short to medium term, including improved body image, reduced dysphoria, and increased participation in social, educational, and physical activities, alongside high levels of patient satisfaction.^{37,38,243,247,250,251} Reported regret is rare, including in the few longer-term follow-up studies that are available.^{37,247,249,250} Studies examining surgical interventions within broader gender-affirming care trajectories report similarly favourable safety and psychosocial outcomes, reinforcing findings from surgery-specific cohorts.^{163,184,196,213,228,252,253,254,255,256,257,258,259,260,261} Adolescents considering or recovering from surgery benefit from ongoing care from multidisciplinary teams, affirming family support, and peer networks.^228,256,259 These findings reinforce the importance of situating surgical interventions within broader trajectories of gender affirmation, including ongoing psychosocial support.

Findings are consistent with the 2021 GAHC Guideline recommendations. Table 6 summarises key implications for guideline development and identifies areas for potential refinement.

We identified one large online survey²⁶² (Online Supplementary Appendix: Table S-K) and one narrative review¹⁴ addressing non-medical gender-affirming practices, including binding, tucking, packing, and padding. Although the evidence base is limited, findings indicate that these practices are meaningful tools through which TGD adolescents manage gender dysphoria, navigate public and social spaces, and feel more at ease in their bodies.^14,262 For many adolescents, these practices are partly driven by limited or delayed access to endocrine and/or surgical GAHC. The available evidence does not indicate serious health risks associated with packing or padding. Physical discomfort related to binding and tucking appears to be common but manageable when TGD youth have access to safer materials and practical guidance.^14,262

Although policy and legal interventions are not addressed as a standalone domain in the SAHCS GAHC Guideline (2021), this rapid review identified eight studies examining the health impact of laws, regulations, and/or administrative systems on TGD youth^{111,261,263,264,265,266,267,268} (Online Supplementary Appendix: Table S-L). No systematic reviews were identified.

Across both qualitative and quantitative studies, restrictive laws and systemic barriers – including outright healthcare bans, regulatory constraints, and administrative obstacles – are consistently associated with poorer mental-health outcomes, including heightened depression, anxiety, suicidality, and social isolation among TGD youth.^{111,261,263,264,265,266,267,268} These associations are observed following both enacted policies and periods of policy uncertainty, suggesting that anticipatory stress and disruption to care pathways contribute to harm.

Conversely, affirming and protective policy environments, including anti-discrimination protections, inclusive institutional guidance, and accessible legal gender recognition, are associated with improved mental-health indicators and, in some analyses, lower substance use and other risk behaviours, as well as enhanced overall well-being.^261,265,267

Parental and caregiver accounts mirror these findings, describing how proposed or enacted care bans intensified depression, anxiety, suicidality, and family distress, particularly where policies disrupted ongoing treatment or created prolonged uncertainty.^263,264,266 Across studies, families reported increased emotional burden, logistical strain, and fear related to maintaining access to care within hostile or unstable policy environments.^263,264,266

The review has several important strengths. It was conceived and led from South Africa by a gender and sexually diverse team with combined methodological, clinical, and lived-experience expertise. This positionality informed decisions about contextualisation and equity, ensuring that the synthesis remains grounded in the legal, social, and service realities of TGD youth in South Africa rather than importing assumptions from high-income settings. To our knowledge, this is the first comprehensive synthesis of GAHC evidence for people under 18 from the Global South.

The search strategy was broad and intentionally inclusive. We conducted a comprehensive multi-database search via EBSCOhost with no language restrictions, deliberately incorporating both current and pathologising terminology for TGD identities and interventions. Cross-mapping showed that 92 of 200 primary studies in our dataset had not appeared in any of the systematic reviews identified, substantially extending the evidence base available for synthesis and highlighting limitations in existing reviews. Data extraction and synthesis followed a structured and transparent process.

As is typical for rapid reviews, several methodological streamlining decisions were made. The review was not prospectively registered. After an initial dual-screening calibration phase, title and abstract screening proceeded with single review, with borderline or uncertain records flagged for second-reviewer input at abstract or full-text stage. Full-text screening and data extraction were not conducted in duplicate. We did not conduct a de novo, outcome-by-outcome risk-of-bias or GRADE/CERQual certainty assessment; instead, we drew on existing appraisals from previous systematic reviews where available and treated them as a secondary interpretive resource rather than as formal ratings for this review. No meta-analysis was attempted because of the extreme heterogeneity of designs, interventions, and outcomes. These choices are consistent with published guidance on rapid reviews, but they inevitably reduce the granularity of quality assessment and may increase susceptibility to subjective judgement compared with a fully resourced systematic review.^{60,63,64,269,270}

Nonetheless, the breadth of the search, the systematic cross-linking of primary studies and prior reviews, the large number of newly identified studies, and the structured narrative synthesis conducted by a multidisciplinary author team support the robustness and practical value of the findings. The review should therefore be understood as a transparent, contextually grounded rapid synthesis rather than a definitive systematic review, and its conclusions should be interpreted with reasoned discernment and attention to the underlying evidentiary limitations.

The evidence assembled in this rapid review – spanning 200 primary studies, 29 academic systematic reviews, and four grey-literature reports – demonstrates a consistent pattern across psychosocial, endocrine, surgical, non-medical, and policy interventions. When TGD young people access affirming psychosocial support, timely endocrine care, and, for older adolescents who require it, surgical interventions, improvements are seen in mental health, dysphoria, and day-to-day functioning. Serious adverse events are rare. Systematic reviews published since 2021, including those commissioned in politically conservative policy environments, echo these findings and report no evidence of population-level harm.^{9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,37,38,39,40,121} This consistency across diverse study designs and outcome domains strengthens confidence in the overall direction of effect, even where formal certainty ratings remain low.

Important limitations in the evidence remain. Most primary studies are observational and/or clinic-based, with small, non-representative samples, short follow-up, and limited geographic diversity. Randomised or quasi-experimental designs are scarce; they are rarely feasible or ethical in this area of care.²⁷¹ Evidence for endocrine and surgical care currently relies heavily on retrospective chart reviews, with variable data quality, inconsistent outcome recording, and limited use of patient-reported measures. Frequent access to multiple and concurrent gender-affirming intervention types by individual TGD youth constrains precision in assessing the impact of particular interventions and requires methodological advancement in the field to disentangle causality while preserving patient autonomy.

Systematic reviews reflect these constraints. Across reviews, varying assessment approaches consistently rate the certainty of evidence as low to very low, because of design limitations, small sample sizes, overlapping patient populations and interventions, short follow-up periods, and narrow geographic scope, rather than conflicting findings. These gaps underscore the need for more robust, longer-term, and inclusive research from the Global South, and South Africa in particular, to better characterise evolving health needs and support equitable, contextually responsive health-system planning.

The certainty of the evidence surrounding GAHC for youth must be understood within the broader reality that low- and very low-certainty evidence underpins a substantial proportion of medical practice overall.^272,273,274 This is particularly true in paediatrics, where ethical and logistical constraints often preclude randomised trials and contribute to persistent inconsistencies across the evidence base, even for common childhood conditions such as asthma and epilepsy.^274,275

The recently updated GRADE Evidence-to-Decision (EtD) framework directly acknowledges these realities. As clarified in the 2025 Core GRADE 7 update,²⁷⁶ low-certainty evidence typically warrants a conditional recommendation, which is an explicit signal that clinicians must engage meaningfully in shared decision-making that centres patient values and preferences. Gordon Guyatt, leading architect of the GRADE framework and co-author of systematic reviews included in this synthesis,^25,26 has explicitly cautioned against the misuse of GRADE in policy advocacy against GAHC for youth.²⁷⁷ Guyatt and colleagues²⁷⁷ emphasise that low-certainty evidence should not be treated as justification for withholding care, but rather as a prompt for careful clinical decision-making that centres patient values, noting:

In South Africa, this is not simply a methodological consideration but a constitutional and statutory imperative. Section 129 of the Children’s Act²⁷⁸ requires respect for adolescents’ evolving capacity to participate meaningfully in decisions about their own healthcare. Where the overall evidence base offers low scientific certainty yet demonstrates consistent patterns across multiple domains and outcomes, the GRADE EtD framework requires clinicians to centre patients’ values, preferences, and lived experience – not to impose blanket restrictions or personal disapproval framed as clinical caution. This approach aligns with the informed-consent model endorsed in South African and international clinical guidelines on GAHC for youth.^1,8

In addition to the domain-specific comparisons with the 2021 SAHCS GAHC Guideline, the evidence synthesised in this review has broader clinical and policy implications that cut across intervention areas and highlight key principles for delivering safe, effective, and contextually grounded care:

Priorities for future research include expanding the evidence base in low- and middle-income countries, strengthening rigour and long-term follow-up, improving the visibility of non-binary adolescents in research, investigating intersecting structural determinants of health, extending evidence on menstrual suppression and adolescent fertility pathways, and deepening TGD youths’ involvement in co-produced and participatory research.