Think again

South Africa is sending mixed signals on the gender medicalisation of young people

Dr Pakishe Aaron Motsoaledi

South Africa’s Health Minister, Dr Pakishe Aaron Motsoaledi, has faced formal questions in the country’s National Assembly about the extent of the use of puberty blockers, cross-sex hormones and surgery among young people and whether parental consent is required.

“[T]his area is currently being reviewed, particularly for children and adolescents, to ensure that all recommendations are in the best interest of this vulnerable population,” Dr Motsoaledi said in a brief reply to the questions concerning cross-sex hormones.

The minister said his National Department of Health lacked data on these hormonal and surgical interventions, and there were no age restrictions for cross-sex hormones. He did not say anything about the role of parental consent.

Dr Motsoaledi is medically trained and sits on the national executive committee of the left-leaning African National Congress, which governs in coalition with the classically liberal Democratic Alliance and other parties.

In his written reply published in October, the minister did not explain the scope or focus of what was being “reviewed,” but he made the remark in the context of a recent challenge to the country’s 2019 listing of cross-sex hormones as “national essential medicines.”

In his answer, Dr Motsoaledi also linked his reference to a South African review to April’s publication of England’s landmark Cass report and the end of routine use of puberty blockers in the UK.

Meanwhile, in South Africa’s province of Western Cape, a circular document promoting the contentious “gender-affirming” treatment model was released on provincial government letterhead in September.

“Nowhere does the document question the safety, evidence, efficacy or iatrogenic harms of cross-sex hormones and surgeries, much less the rapid and unexplained epidemiological shift in the patient cohort over time,” said a spokesperson for the parents’ group Our Duty South Africa.

In August, the regulatory Health Professions Council of South Africa issued a warning about the off-label use of drugs for minors with gender dysphoria and said it might develop some form of guidance for practitioners.

The council said that the executive committee of the Medical and Dental Professions Board—which protects the public by regulating the profession and can deregister doctors—had “issued an advisory to practitioners that the [use of off-label] drugs needs to be done with care, consent and be based on scientific evidence. Practitioners are advised to adhere to the above-mentioned advisory.”

The National Department of Health’s spokesman, Mr Foster Mohale, said that off-label use referred to the use of a medicine in a way different from the market authorisation; for example, he said, the medicine might be “used for different age groups, indications or routes of administration.”

“Off-label differs from unregistered medicines which have not been approved by the South African Health Products Regulatory Authority,” Mr Mohale told GCN.

“A common thread [in the activist narrative] has been the recommendation that South African healthcare providers adopt gender-affirming health care, that it should be provided at a primary care level (including rural areas), that staff need to be trained to provide it, and that it should be taught at medical schools so that it will become part of mainstream medical care in South Africa.”—Drs Janet Giddy, Allan Donkin and Reitze Rodseth, opinion article, TimesLIVE, 19 May 2024

Video: Baroness Hilary Cass, speaking on Tuesday in the UK House of Lords, debunks the gender clinicians’ claim that giving puberty blockers off-label to interrupt the normally timed puberty of a gender-distressed minor is the same treatment as using those drugs for the licensed purpose of blocking the precocious (or premature) puberty of a young child.

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Questions for the minister

Dr Motsoaledi’s office did not reply when GCN asked for details of the South African review mentioned by the minister in his written answer in October.

It is not clear how such a review might relate to the warning issued by the health professions council and the challenge to the listing of cross-sex hormones as essential medicines.

Questions about gender medicalisation of minors and young adults were put to the minister in October in the National Assembly by Dr Karl Willem du Pré le Roux, who is the Democratic Alliance deputy spokesperson on health.

Dr le Roux, a doctor and researcher who chaired the Rural Doctors’ Association of Southern Africa from 2008 to 2012, had asked about the extent of cross-sex hormone use among minors and young adults with gender dysphoria, and whether parental consent was required for patients under age 18.

He also asked for statistics on puberty blocker prescriptions and “gender transformation surgery,” and whether proper parental consent had been obtained in the case of minors.

Dr Motsoaledi’s replies highlighted a lack of government oversight and a data deficit.

“[Prescription of puberty blockers] is a highly specialised function, provided by highly trained endocrinologists, and because it is a matter of specialists [in relationship] to their patients, the [National] Department of Health does not keep any list whatsoever,” he said.

Nor, he said, did his department “currently [have] oversight and visibility of the number of patients initiated on testosterone or oestrogen for gender dysphoria.”

This treatment was managed at multidisciplinary clinics in hospitals, Dr Motsoaledi said.

As for gender surgery, this too was the province of hospitals, according to the minister.

“Neither the provincial nor national departments of health keep a list of these people [undergoing gender surgery], they are kept in hospitals, and we are still in the process of acquiring this information from the hospitals,” Dr Motsoaledi said.

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Essential?

In his answers to Dr le Roux, Dr Motsoaledi noted that the cross-sex hormones oestrogen and testosterone had been approved for gender dysphoria by the National Essential Medicines List Committee (NEMLC) in December 2019.

“This recommendation informs use at tertiary and quaternary levels of care, with initiation of treatment by a multidisciplinary specialist team, with continued treatment access down referred to lower levels of care as needed,” he said.

“There are currently no restrictions placed on age for consideration for this care, with decisions to be made by the multidisciplinary specialist team.”

However, the minister said, this listing of cross-sex hormones was under appeal.

He said puberty blockers—gonadotrophin-releasing hormone (GnRH) analogues—had been approved for treatment of precocious (or premature) puberty. The use of these drugs for gender dysphoria had not been reviewed by the NEMLC, he said.

The evidence for the use of puberty blockers and cross-sex hormones with gender-distressed minors is very weak and uncertain, according to multiple systematic reviews undertaken independently since 2019 in Finland, Sweden, Germany, the UK and the American state of Florida.

However, the NEMLC’s 2019 decision is being used in South Africa by advocates of the gender-affirming treatment approach to encourage family doctors to prescribe cross-sex hormones.

“The hormones used in [gender-affirming healthcare] have been shown to be safe and effective and in 2019 gender-affirming hormones were approved by the South African National Essential Medicine List Committee NEMLC for tertiary-level of care,” said a 2023 article in the journal of South African Family Practice.¹

“This has been an important step to provide access to gender-affirming hormone therapy, and more work is needed to ensure such treatment be included in the primary and secondary hospital [essential medicine lists.] Many transgender programmes are managed by NGOs within a primary health care setting,” the article said.

The 2019 technical reports relied on by the NEMLC cite two studies—a 2010 systematic review and meta-analysis by Murad et al, and a 2012 cross-sectional study by Gorin-Lazard et al.

The NEMLC reports cite Murad et al as showing improvements in gender dysphoria, psychological symptoms, quality of life and sexual function for patients given oestrogen and testosterone as cross-sex hormones.

The reports do not mention the conclusion by Murad et al that the evidence for these improvements is of “very low quality.”

As for Gorin-Lazard et al, the NEMLC reports themselves acknowledge that this cross-sectional study had no “hard clinical outcomes,” only subjective measures such as better quality of life.

Mr Mohale from the National Department of Health said the NEMLC was “currently evaluating the area of cross-sex hormone use following an appeal received.”

“As the NEMLC review work is currently underway, we cannot outline the nature of the appeal at this point,” the spokesman told GCN.

“It is however important to note that since the publication of the Cass review, the use of cross-sex hormones in children has come into the spotlight, which will be comprehensively evaluated by NEMLC.”

The appeal was lodged in July by the group First Do No Harm South Africa, a voluntary association of professionals concerned about the evidence base for the medicalisation of gender dysphoria in young people.

“[E]ither the [Democratic Alliance] has no control over the policies being passed in the departments they run, or they are way further to the Left than they sell themselves as to their voters.”—Journalist Robert Duigan, opinion article, The Cape Independent, 20 September 2024

Off the planet

Meanwhile, in the province of Western Cape, there is concern and confusion over what appears to be trans activist-driven policymaking.

In September, a 26-page circular surfaced on Western Cape government letterhead with the title “Evidence-Based Care for Transgender and Gender-Diverse People position statement.”

It was posted in a social media group used by health professionals, chiefly doctors.

Evidence-based care was defined in the document as interventions “designed to support and affirm an individual’s gender identity when it conflicts with the gender they were assigned at birth.”

The position statement circular, addressed to directors and executives within the Western Cape Department of Government Health and Wellness, offered no hint that medical affirmation might be risky or contentious.

It suggested health authorities should collaborate with “LGBTIQA+” lobbies in order to “generate rich evidence.”

The advisory group behind the circular reportedly included a representative of the trans activist organisation Gender Dynamix.

The document showcased the amateur-activist cartoon figure, the Genderbread Person, with “identity” lodged in the brain, “orientation” in the heart, and “sex” in the genitals.

Giving credit to the Desmond Tutu Health Foundation, this government document featured a pseudo-cosmological graphic entitled the “Sexual Orientation and Gender Identity universe,” with the stated aim to educate people in “key terms as they relate to gender identity differences.”

Male, female, genderfluid, straight, queer, agender—some 21 terms were depicted as celestial bodies complete with orbits. And then the document itself disappeared like a shooting star.

It had attracted some sharp criticism, with journalist Robert Duigan on The Cape Independent news site commenting—

“The Western Cape government has released a new circular to all medical professionals in the province, instructing them on the implementation of a radical transgender policy that will see all patients treated as potential transgender or ‘genderfluid’ people, which indirectly pressures doctors into giving surgical and chemical treatment to anyone who claims to feel that they ought to be a member of the opposite sex, and encourages patients to see the idea of transgenderism as psychologically normal.”

Although the circular claimed the position statement was approved in August, the document is not to be found on any official website of the Western Cape government.

Asked about its status, one of the officials named in the document said it was “internal guidance” and would revert to “a draft format for wider consultation” until end-January 2025.

The spokesperson for Our Duty South Africa expressed “deep concern at the level of trans-activist capture revealed by the circular.”

“The document proposes to unquestioningly mainstream trans-activist demands throughout the provincial health department—from increasing provision/access to ‘gender-affirming health care’ to moving away from ‘binary’ sex-based data capture in the department,” the spokesperson said.

“We have real concerns about who has been advising and influencing key position holders in the [provincial health department,] and we call for a moratorium on all ‘gender-affirming health care,’ which causes severe harm to the bodies of those receiving it.”

Our Duty also urged a moratorium on “all policies designed to ‘queer’ health care and society at large, which disproportionately harm and endanger vulnerable, especially neurodivergent people, lesbian, gay and bisexual people, and women in general.”

1. The authors of the article include Chris/tine McLachlan, who chairs the Professional Association of Transgender Health, South Africa, and is a member of the World Health Organisation panel to develop a gender-affirming treatment guideline.