This letter by Mark E. Patrick responds to Tomson et al.1 (2021). It is followed by a response from the Editor-in-Chief and Managing Editor of the Southern African Journal of HIV Medicine, and the Chief Executive Officer of the Southern African HIV Clinicians Society.
In 2021, the Southern African HIV Clinicians Society (SAHCS) published the Southern African HIV Clinicians Society Gender-Affirming Healthcare Guideline for South Africa in this Journal.1 On 13 March 2026, the Journal published an editorial expression of concern that the guideline ‘did not undergo the Journal’s standard journal-led external peer-review process’.2 The guideline draws on the World Professional Association for Transgender Health (WPATH) Standards of Care, Version 7 (SOC-7), published in 2012.3
International developments have raised concerns about the scientific rigour4 and ethical foundation of WPATH’s approach.5The WPATH Files: Pseudoscientific Surgical and Hormonal Experiments on Children, Adolescents, and Vulnerable Adults offers internal perspectives on WPATH’s practices.6 As a result of state-led systematic reviews, the United Kingdom,7 Finland,8 Sweden,9 and a growing number of other countries no longer rely on WPATH and its Standards of Care for minors with gender-related distress.
Mirroring WPATH’s SOC-7, the SAHCS guideline recommends gender-affirming healthcare (GAHC) for transgender and gender-diverse (TGD) people, including minors.
A reading of the SAHCS guideline raises pressing questions:
What is the medical definition of a TGD child, adolescent, or young adult?
What is the epidemiology of being TGD, and how is this understood medically?
What is the scientific basis for asserting that people of any age can change their sex?
The SAHCS guideline provides us with no medically coherent, evidence-based definition for the term ‘TGD’, nor does it provide us with biologically plausible explanations for the determinants of being TGD, or a robust, evidence-based rationale for its recommendations. The SAHCS guideline asserts that being TGD is an identity; that clients can change sex at any age; and that this must be performed through social, medical and surgical interventions.
The SAHCS guideline details core components of gender-affirming healthcare, including recommendations for:
Puberty blockers administered off-label to halt normal pubertal development.
Cross-sex hormones administered off-label to induce opposite sex body morphology.
Surgical interventions such as breast excision, castration, penile inversion vaginoplasty, and phalloplasty utilising forearm muscle and skin grafts.
For these interventions, the SAHCS guideline advises that:
[A] child who is over 12 years of age, … may independently give informed consent to … intervention for GAHC without legally requiring the support or consent of their parents/legal guardians (p. 21).10
The irreversible and lifelong consequences of these interventions and the consent process recommended demand rigorous scientific scrutiny and ethical oversight. Because of the enormity of these interventions and their impact on young and vulnerable people, the publication by the SAHCS of such a guideline demands thorough, independent review.
Noting that there was no journal-led external peer-review, that the National Department of Health has not endorsed or approved this guideline, and that the Health Professions Council of South Africa (HPCSA) has issued an advisory on the off-label use of drugs to treat gender dysphoria,11 the following questions regarding the guideline need answers from the SAHCS:
Is it endorsed by the full SAHCS board?
Has it been endorsed by any independent medical bodies, for example, the South African Paediatric Association?
Were the SAHCS guideline’s recommendations on social transition, puberty blockers, cross-sex hormones, and surgeries formulated using globally recognised best-practice frameworks for guideline development, such as AGREE II12 or GRADE13?
Do the SAHCS guideline’s consent recommendations meet independently assessed medical, ethical, legal, and human rights standards?
Should patient harm result from using the SAHCS’s guideline, what medico-legal defences exist for individual practitioners, and how will the SAHCS and the Journal support them? (In February 2026, de-transitioner Fox Varian successfully sued her psychologist and plastic surgeon for breast removal at age 16. Casting doubt on his own WPATH guideline, Dr Loren Schechter, plastic surgeon and current WPATH president-elect, a witness for Varian, testified that SOC-7 should not be considered a legal standard of care.14)
The SAHCS exists to provide high-quality leadership in HIV care, including for TGD people. The mission of its Journal is to disseminate original research and support high-level learning in HIV medicine.15 It is concerning that the SAHCS and its Journal – in publishing this guideline – recommend interventions that cause sterilisation and create lifelong medical dependency.
The SAHCS is a trusted and ‘powerful and independent voice within Southern Africa, with key representation from the most experienced and respected professionals working in the fight against HIV’,16 The SAHCS and its Journal should maintain their scientific and ethical integrity by focusing on their core mission.
Owning and publishing a guideline that recommends sex-change interventions in children, adolescents and young adults raises serious questions of patient safety, medical ethics and publication integrity.
The SAHCS guideline did not undergo the standard journal-led external peer-review process. It does not fall within the scope of the Society or its Journal. For reputational and medico-legal reasons, the SAHCS needs to remove this guideline from its distinguished collection of HIV-medicine guidelines.
AcknowledgementsCompeting interests
The author declares that no financial or personal relationships inappropriately influenced the writing of this article.
CRediT authorship contribution
Mark E. Patrick: Conceptualisation, Writing – original draft, Writing – review & editing. The author confirms that this work is entirely their own, has reviewed the article, approved the final version for submission and publication, and takes full responsibility for the integrity of its findings.
Data availability
Data sharing is not applicable to this article as no new data were created or analysed in this study.
Disclaimer
The views and opinions expressed in this article are those of the author and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The author is responsible for this article’s results, findings, and content.
ReferencesTomsonA, McLachlanC, WattrusC, et al. Southern African HIV Clinicians Society gender-affirming healthcare guideline for South Africa. South Afr J HIV Med. 2021;22(1):1299. https://doi.org/10.4102/sajhivmed.v22i1.1299MaartensG. Editorial expression of concern for the guideline ‘Southern African HIV Clinicians Society gender-affirming healthcare guideline for South Africa’. South Afr J HIV Med. 2026;27(1):1813. https://doi.org/10.4102/SAJHIVMED.v27i1.1813ColemanE. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend. 2012;13(4):165–232. https://doi.org/10.1080/15532739.2011.700873ZhangY, JanusD, KaltialaR, KarvonenM, PtakJJ, Yepes-NunezJJ. Quality of the World Professional Association for Transgender Health Guideline Standards of Care 8: An appraisal using the AGREE II instrument. Arch Sex Behav. 2026. https://doi.org/10.1007/s10508-025-03399-6Department of Health and Human Services. Treatment for pediatric gender dysphoria: Review of evidence and best practices [homepage on the Internet]. Washington, DC: HHS; 2025[cited 2026 Mar 20]. Available from: https://opa.hhs.gov/sites/default/files/2025-11/gender-dysphoria-report.pdfHughesM. The WPATH files: Pseudoscientific surgical and hormonal experiments on children, adolescents, and vulnerable adults [homepage on the Internet]. c2024 [cited 2026 Mar 20]. Available from: https://environmentalprogress.org/big-news/wpath-filesCassH. Independent review of gender identity services for children and young people: Final report. London: NHS England; 2024.COHERE. Recommendation of the Council for Choices in Health Care in Finland (PALKO / COHERE Finland): Medical treatment methods for dysphoria related to gender variance in minors [homepage on the Internet]. c2020 [cited 2025 Mar 20]. Unofficial Translation. Available from: https://segm.org/sites/default/files/Finnish_Guidelines_2020_Minors_Unofficial%20Translation.pdfThe National Board of Health and Welfare. Updated recommendations for hormone therapy for gender dysphoria in young people. Sweden; 2022. Available from https://www.socialstyrelsen.se/om-socialstyrelsen/pressrum/press/uppdaterade-rekommendationer-for-hormonbehandling-vid-konsdysfori-hos-unga/TomsonA, McLachlanC, WattrusC, et al. Southern African HIV Clinicians Society gender-affirming healthcare guideline for South Africa – expanded version. 2021[cited 2026 Mar 20]. Available from: https://sahivsoc.org/Files/SAHCS%20GAHC%20guidelines-expanded%20version_Oct%202021(3).pdfHealth Professions Council of South Africa. Advisory on off-label use of drugs [homepage on the Internet]. Pretoria: HPCSA; c2024 [updated 2024 Aug] [cited 26 Mar 20]. Available from: https://www.hpcsa-blogs.co.za/advisory-on-off-label-use-of-drugs/BrouwersMC, KhoME, BrowmanGP, et al. AGREE II: Advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839–E842. https://doi.org/10.1503/cmaj.090449GuyattGH, OxmanAD, VistGE, et al. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–926. https://doi.org/10.1136/bmj.39489.470347.ADRyanB. WPATH’s trans-care bible ‘is not considered the standard of care’ – Unheard testimony from the $2M Detransitioner Lawsuit [homepage on the Internet]. c2026 [cited 2026 Mar 20]. Available from: https://benryan.substack.com/p/the-historic-detransitioner-lawsuitsSouthern African Journal of HIV Medicine [homepage on the Internet]. n.d.[cited 2026 Mar 20]. Available from: https://sahivsoc.org/Subheader/Index/southern-african-journal-of-hiv-medicineSouthern African HIV Clinicians Society. Celebrating 25 years [homepage on the Internet]. n.d.[cited 2026 Mar 20]. Available from: https://sahivsoc.org/Subheader/Index/celebrating-25-yearsResponse to: ‘The SAHCS genderaffirming healthcare guideline and the <italic>Southern African Journal of HIV Medicine</italic>: Scientific, ethical and editorial concerns’
Gary Maartens, Editor-in-Chief, Southern African Journal of HIV Medicine, editor@sajhivmed.org.za
Fiona Storie, Chief Executive Officer, Southern African HIV Clinicians Society
Camilla Wattrus, Managing Editor, Southern African Journal of HIV Medicine, and Clinical Director, Southern African HIV Clinicians Society
We thank Dr Patrick for raising his concerns about the SAHCS Gender-Affirming Healthcare Guideline, the condensed version of which was published in the Southern African Journal of HIV Medicine on 28 September 2021.1
Regarding the specific questions raised: the SAHCS Board of Directors acts as a governing body and does not manage day-to-day activities (including guidelines) of the Organisation; a list of organisations endorsing the guideline, the guideline process, legal disclaimer, and consent are all available in the expanded version of the guideline.2
Regarding the statement, ‘SAHCS needs to remove the guideline from its distinguished collection of HIV-medicine guidelines’, the journal received a formal retraction request on 06 October 2025 based on scientific, ethical and editorial concerns. The journal referred the matter for a formal and independent review by the Committee on Publication Ethics (COPE), https://publicationethics.org, in alignment with their Retraction Guidelines. Following consultation with COPE, the Editorial Board, acting within its mandate, determined that retraction of the guideline was not warranted; however, an Expression of Concern regarding the peer review process was published,3 as cited by Dr Patrick.
The journal considers the matter addressed.
ReferencesTomsonA, McLachlanC, WattrusC, et al. Southern African HIV Clinicians’ Society gender-affirming healthcare guideline for South Africa. South Afr J HIV Med. 2021;22(1):1299. https://doi.org/10.4102/sajhivmed.v22i1.1299TomsonA, McLachlanC, WattrusC, et al. Southern African HIV Clinicians Society gender-affirming healthcare guideline for South Africa – expanded version [homepage on the Internet]. 2021[cited 2026 Mar 20]. Available from: https://sahivsoc.org/Files/SAHCS%20GAHC%20guidelines-expanded%20version_Oct%202021(3).pdfMaartensG. Editorial expression of concern for the guideline ‘Southern African HIV Clinicians Society gender-affirming healthcare guideline for South Africa’. South Afr J HIV Med. 2026;27(1):a1813. https://doi.org/10.4102/SAJHIVMED.v27i1.1813
How to cite this article: Patrick ME. The SAHCS gender-affirming healthcare guideline and the Southern African Journal of HIV Medicine: Scientific, ethical and editorial concerns. S Afr J HIV Med. 2026;27(1), a1830. https://doi.org/10.4102/sajhivmed.v27i1.1830