# Rapid Review of Gender-Affirming Healthcare for Children and Adolescents: Evidence Synthesis (2021–2025) and Recommendations for South Africa

## TL;DR

This paper reviews evidence on gender-affirming healthcare for youth in South Africa, highlighting the importance of affirming environments and the need for accessible, equitable care.

## Contribution

The paper synthesizes recent global evidence and aligns it with South African realities to provide locally relevant recommendations for gender-affirming healthcare.

## Key findings

- Affirming environments significantly reduce distress and improve mental health outcomes for transgender and gender-diverse youth.
- Structural barriers like limited staffing and financial constraints in South Africa hinder access to gender-affirming care.
- Protective laws and policies are linked to better mental health and safety for TGD youth.

## Abstract

In South Africa, transgender and gender-diverse (TGD) children and adolescents continue to navigate health systems shaped by deep inequalities, limited specialised services, and persistent stigma. Here at home, these young people too often move through environments marked by the legacies of apartheid, economic exclusion, uneven service delivery, and ongoing social prejudice. These layered forms of inequality shape how families, caregivers, teachers, and communities are able to support the young people they love.

At the same time, international debates about gender-affirming healthcare (GAHC) for youth have become increasingly polarised, often driven by narratives that do not reflect South African realities or the rights-based framework of our Constitution. Much of this global rhetoric arrives at our shores without acknowledgment of our country’s unique social fabric, woven from resilience, cultural diversity, and a deep collective commitment to justice and dignity, even as we continue healing from our past.

This rapid review brings together rigorous, peer-reviewed evidence published from 2021–2025 on GAHC for youth under the age of 18 to help us understand what works, what is safe, and what young people need. It builds on the 2021 GAHC Guideline supported by Southern African HIV Clinicians Society (SAHCS), which is South Africa’s current clinical framework for gender-affirming care, ensuring that our practices remain aligned with the best available evidence and our constitutional values.

It also serves a deeper purpose: it offers guidance to the parents, families, caregivers, educators, health-workers, faith leaders, and communities who are trying to walk alongside TGD children and adolescents with compassion and clarity, sometimes in the face of fear, uncertainty, or misinformation.

It reflects the combined expertise of a queer- and trans-led team committed to dignity, equity, and affirming care, which are values consistent with Ubuntu, Batho Pele, and the broader South African human-rights tradition. This is work rooted in the understanding that a young person does not grow or struggle alone; they grow in families, in communities, in classrooms, in clinics, and in the collective dreams we hold for a more just and caring society.

This review is therefore not only a scientific exercise. It is an act of accountability. An offering of care. A step toward ensuring that every young person in this country, regardless of gender identity, race, class, disability, or geography, is met with dignity, safety, and support. It is work that recognises our shared responsibility to build a South Africa where all children and youth can thrive.

Across 200 peer-reviewed research articles, 29 systematic reviews and 4 rigorous technical reports included in this rapid review, one picture emerges clearly, a picture that resonates with common sense, lived experience, and the stories told by TGD youth across the country:

An affirming home, an accepting teacher, a safe clinic, or a supportive friend can dramatically reduce distress, depression, and feelings of isolation. Young people become more confident, more hopeful, and more connected to their communities. Their school attendance improves. Their relationships deepen. Their sense of belonging grows.

Internationally, these structural barriers are consistently linked to poorer wellbeing for TGD youth. In South Africa, many delays have nothing to do with safety or clinical readiness, they stem from limited staffing, uneven provincial capacity, referral bottlenecks, and financial constraints. For young people, these delays are not neutral. They often result in worsening anxiety, deepened dysphoria, and increased risk of self-harm or suicidality.

Puberty pausers do not override who a child is; rather, they give young people time; time to breathe, time to grow, time to make developmentally appropriate decisions about their bodies without the pressure of unwanted pubertal changes. Puberty pausers and gender-affirming hormones produce expected and desired outcomes under specialist monitoring. Side effects are usually mild and reversible, and mental-health outcomes are mostly stable or improved.

These surgeries are not undertaken lightly, are generally only offered to older adolescents, and are far less common than some public discussions suggest. When masculinising chest surgery is offered, it shows low complication rates and high satisfaction. Many young people report significant improvements in body image, participation in daily life, and overall wellbeing.

Policies shape lives. They decide whether a young person can change their name at school, whether a clinic has clear protocols, whether there is protection against discrimination, or whether a family must fight through unnecessary red tape.
Restrictive laws are consistently linked to increased distress, self-harm, and suicidality.Protective laws such as anti-discrimination policies and access to legal gender recognition improve mental health and safety.

Restrictive laws are consistently linked to increased distress, self-harm, and suicidality.

Protective laws such as anti-discrimination policies and access to legal gender recognition improve mental health and safety.

In short: Affirming environments promote healthier outcomes. Restrictive environments are linked to distress and harm.

Almost all of the global research on GAHC for youth comes from high-income countries, places with more specialised services, shorter waiting times, and stronger safety nets than those available to most South Africans. Yet the findings are still clear and relevant when interpreted through a local lens:

Poverty, community violence, discrimination, school-based exclusion, xenophobia, racism, homophobia, and limited access to specialised care all intersect to shape the mental health of TGD young people. These realities amplify the need for safe, affirming services, they do not diminish it.

Even families with medical aid often face high out-of-pocket costs. For many, this makes care inaccessible, reinforcing historical patterns of inequity.

Some provinces have dedicated clinicians, while others rely on referral pathways that stretch across hundreds of kilometres. Rural youth often carry the heaviest burden, travelling long distances, missing school, or facing stigma when trying to access support.

South Africa’s past left a legacy of fragmented health systems and unequal access. But it also left a legacy of resilience, community solidarity, and a collective instinct to protect our most vulnerable.

This makes affirming, timely, and coordinated care even more essential here, not less.

The evidence base is growing, but not perfect, and it is important for families and communities to understand its limitations without misinterpreting them:
Most studies are observational, meaning they reflect real-world experiences rather than controlled clinical trials.Follow-up periods are short, especially for adolescents whose needs evolve rapidly over time.Non-binary and neurodivergent youth remain underrepresented, even though they make up an important part of our community.Very few studies come from the Global South, including African nations, where cultural contexts, resource constraints, and support systems differ.Randomised trials are not feasible in this field, given the small population, inability to blind participants or prevent them from accessing related interventions, and the ethical concerns of withholding needed care.

Most studies are observational, meaning they reflect real-world experiences rather than controlled clinical trials.

Follow-up periods are short, especially for adolescents whose needs evolve rapidly over time.

Non-binary and neurodivergent youth remain underrepresented, even though they make up an important part of our community.

Very few studies come from the Global South, including African nations, where cultural contexts, resource constraints, and support systems differ.

Randomised trials are not feasible in this field, given the small population, inability to blind participants or prevent them from accessing related interventions, and the ethical concerns of withholding needed care.

These limitations reflect gaps and constraints in the global research landscape, not a lack of benefit. Instead, they highlight the importance of building a stronger African evidence base in the years ahead.

The findings are remarkably consistent: Gender-affirming healthcare is effective and life-enhancing for young people who want it, with established safety profiles under professional care.

This rapid review supports the continued implementation and strengthening of the SAHCS GAHC Guideline. It also calls for policies and services that uphold the constitutional rights, dignity, and humanity of TGD youth.

But beyond the science, there is a deeper message for us as a country: When a child is affirmed, they are more likely to stay in school, maintain strong family bonds, build a sense of belonging, and grow into adults who contribute meaningfully to their communities. When a child is denied care and support, we risk losing them to despair, to disconnection, or to preventable harm.

When we affirm, young people thrive. When we delay or deny, they suffer.

This review is a reminder that every young person deserves care that sees them, respects them, and allows them to grow into who they truly are without fear. It is a call to parents, teachers, health professionals, faith leaders, policymakers, and community members to walk alongside our youth with compassion and clarity.

In the spirit of Ubuntu, we remember: A child’s wellbeing is never theirs alone. It is held in the hands of all of us.

In a context of growing international controversy and rising ideological opposition to gender-affirming healthcare (GAHC) overseas, South African stakeholders require an up-to-date, locally grounded, evidence-informed assessment of the health outcomes associated with gender-affirming interventions for transgender and gender-diverse (TGD) youth. While most of the global debate is shaped by political and cultural dynamics of the Global North, South Africa must interpret emerging evidence through its own constitutional, historical, and socio-cultural commitments, including the enduring principles of Ubuntu, Batho Pele, and a public health tradition rooted in equity and collective wellbeing.

This Rapid Review, which was not prospectively registered, synthesises research indexed between January 2021 and August 2025 to evaluate whether new evidence supports updates or refinements to the 2021 GAHC Guideline supported by Southern African HIV Clinicians Society (SAHCS), which is South Africa’s current clinical framework for gender-affirming care, ensuring that our practices remain aligned with the best available evidence and our constitutional values. The review was conducted by a queer- and trans-led team positioned in South Africa whose methodological, clinical, advocacy, and lived-experience expertise shaped the interpretation of evidence through an equity, rights-based, and context-sensitive lens. This positionality strengthens rather than biases the review; it ensures that the analysis attends to the realities of unequal access, historical trauma, and structural barriers that characterise healthcare experiences for many young people in South Africa.

The review sought to:
Synthesise empirical evidence (2021–2025) across psychosocial, endocrine, surgical, policy, and non-medical gender-affirming interventions for TGD youth under 18, with attention to both benefits and potential harms.Assess alignment with the 2021 SAHCS GAHC Guideline, identifying where new data support, challenge, refine, or expand existing recommendations.Interpret global findings within South Africa’s unique realities, including constitutional protections, historical inequities, health-system constraints, cultural diversity, and intersecting structural barriers such as poverty, violence, stigma, racism, sexism, xenophobia, and homophobia.

Synthesise empirical evidence (2021–2025) across psychosocial, endocrine, surgical, policy, and non-medical gender-affirming interventions for TGD youth under 18, with attention to both benefits and potential harms.

Assess alignment with the 2021 SAHCS GAHC Guideline, identifying where new data support, challenge, refine, or expand existing recommendations.

Interpret global findings within South Africa’s unique realities, including constitutional protections, historical inequities, health-system constraints, cultural diversity, and intersecting structural barriers such as poverty, violence, stigma, racism, sexism, xenophobia, and homophobia.

In doing so, the review aims to support clinicians, policy-makers, psychosocial providers, educators, civil society organisations, and families in providing care that is evidence-based, developmentally appropriate, and aligned with the rights and dignity of TGD youth.

A rapid review approach was adopted, consistent with PRISMA 2020 and PRISMA-RR guidance, and adapted to balance rigour with timeliness. Searches spanning January 2021 to August 2025 were conducted across 12 databases via EBSCO Host (University of Pretoria), supplemented by searches of ClinicalTrials.gov and the ISRCTN registry and targeted searches for recent systematic reviews, with search date limits of 2021-01-01 to 2024-12-31 and 2025-01-01 to 2025-12-31. The review team used Rayyan for screening and applied streamlining methods appropriate for rapid-review designs without compromising transparency.

Included:
Peer-reviewed primary studies (N ≥ 5) reporting psychosocial or physical health outcomes of interventions aimed at TGD youth (<18), including interventions involving family systems, caregivers, educators, or public policy.Systematic, scoping, and narrative reviews with transparent and reproducible search protocols.Grey literature systematic reviews meeting the same methodological standards.Studies reporting family-level outcomes that included data for TGD youth.

Peer-reviewed primary studies (N ≥ 5) reporting psychosocial or physical health outcomes of interventions aimed at TGD youth (<18), including interventions involving family systems, caregivers, educators, or public policy.

Systematic, scoping, and narrative reviews with transparent and reproducible search protocols.

Grey literature systematic reviews meeting the same methodological standards.

Studies reporting family-level outcomes that included data for TGD youth.

Excluded:

Commentaries, opinion pieces, editorials, case reports or case series with N < 5, reviews lacking reproducible search strategies, and studies that described the health status or health history of TGD youth without reporting any health or psychosocial outcomes from some type of intervention were excluded.

Across all eligible reports, any empirically assessed health or psychosocial outcomes were included, and all empirical designs (quantitative, qualitative, and mixed-methods) were eligible; no meta-analysis was conducted because of extreme heterogeneity in populations, interventions, and outcome measures, so findings were synthesised narratively by intervention domain.

Two custom Airtable extraction tools were used to extract data from primary studies and systematic reviews respectively, capturing study characteristics, populations, interventions, outcomes, and key results. Formal de novo risk-of-bias or certainty grading across all individual studies was not undertaken; instead, where available, existing methodological appraisals and certainty assessments from included systematic reviews were used qualitatively to inform interpretation. Findings from both types of report were then synthesised narratively across five domains:
Psychosocial interventionsEndocrine interventionsSurgical interventionsNon-medical gender-affirming practicesPolicy and legal interventions

Psychosocial interventions

Endocrine interventions

Surgical interventions

Non-medical gender-affirming practices

Policy and legal interventions

The synthesis prioritised clinical relevance, harms and benefits, and equity considerations, with explicit attention to implications for South Africa’s health systems, socio-economic landscape, and constitutional obligations. Partial financial support for three authors was provided by Gender DynamiX.

The final dataset comprised 200 primary studies, 29 academic systematic reviews, and four grey literature systematic reviews, covering psychosocial, endocrine, surgical, non-medical, and policy/legal interventions for TGD youth.

Psychosocial interventions:
Affirming psychosocial interventions, including support for social transition, family involvement, and safer school environments are associated with meaningful reductions in distress, anxiety, and suicidality. Neurodiversity-informed approaches support engagement and wellbeing for neurodivergent TGD adolescents.Affirming interventions are linked to improvements in emotional regulation, resilience, sense of belonging, school participation and day-to-day functioning. No study reported harms arising from affirming psychosocial care.In contrast, practices that delay, withhold, or discourage affirmation, including identity-change efforts, are consistently associated with psychological harm.Psychosocial care is not ancillary; it is an essential pillar of gender-affirming care for TGD children and adolescents, particularly in contexts shaped by structural violence, poverty, stigma, and limited mental-health resources.

Affirming psychosocial interventions, including support for social transition, family involvement, and safer school environments are associated with meaningful reductions in distress, anxiety, and suicidality. Neurodiversity-informed approaches support engagement and wellbeing for neurodivergent TGD adolescents.

Affirming interventions are linked to improvements in emotional regulation, resilience, sense of belonging, school participation and day-to-day functioning. No study reported harms arising from affirming psychosocial care.

In contrast, practices that delay, withhold, or discourage affirmation, including identity-change efforts, are consistently associated with psychological harm.

Psychosocial care is not ancillary; it is an essential pillar of gender-affirming care for TGD children and adolescents, particularly in contexts shaped by structural violence, poverty, stigma, and limited mental-health resources.

Endocrine interventions:
Puberty pausing medication and gender-affirming hormone therapy (GAHT) produce expected and desired physiological outcomes under specialist monitoring.Adverse events are generally mild, reversible, and consistent with known paediatric endocrine profiles.Mental health outcomes ranged from neutral to improved, with evidence that timely access (as opposed to prolonged non-clinical delay) is associated with lower suicidality, improved mood, enhanced quality of life, and greater appearance congruence and functioning.Adolescents receiving endocrine care report high treatment satisfaction, high continuation into adulthood, and very low rates of regret.Menstrual suppression is a safe, effective, and highly valued component of care for TGD adolescents who menstruate, reducing pain and menstrual-related dysphoria and resulting in high amenorrhoea rates and strong satisfaction.Fertility preservation through gamete preservation appears feasible and generally safe for adolescents, although accessibility for patients who are interested is constrained by cost, procedural dysphoria, and timing of referral. These factors combined highlight the importance of early, developmentally appropriate fertility counselling.

Puberty pausing medication and gender-affirming hormone therapy (GAHT) produce expected and desired physiological outcomes under specialist monitoring.

Adverse events are generally mild, reversible, and consistent with known paediatric endocrine profiles.

Mental health outcomes ranged from neutral to improved, with evidence that timely access (as opposed to prolonged non-clinical delay) is associated with lower suicidality, improved mood, enhanced quality of life, and greater appearance congruence and functioning.

Adolescents receiving endocrine care report high treatment satisfaction, high continuation into adulthood, and very low rates of regret.

Menstrual suppression is a safe, effective, and highly valued component of care for TGD adolescents who menstruate, reducing pain and menstrual-related dysphoria and resulting in high amenorrhoea rates and strong satisfaction.

Fertility preservation through gamete preservation appears feasible and generally safe for adolescents, although accessibility for patients who are interested is constrained by cost, procedural dysphoria, and timing of referral. These factors combined highlight the importance of early, developmentally appropriate fertility counselling.

Surgical interventions:
Evidence for patients under age 18 is limited but highly consistent and focuses almost exclusively on masculinising chest reconstruction, which is the only gender-affirming surgery routinely accessed by adolescents internationally.Within multidisciplinary programmes, masculinising chest surgery shows very low complication and revision rates, with safety profiles favourably comparable to those seen in adult or cisgender groups undergoing analogous breast procedures.Psychosocial outcomes are 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.Regret is rare, even in the longer-term follow-up studies that are available.

Evidence for patients under age 18 is limited but highly consistent and focuses almost exclusively on masculinising chest reconstruction, which is the only gender-affirming surgery routinely accessed by adolescents internationally.

Within multidisciplinary programmes, masculinising chest surgery shows very low complication and revision rates, with safety profiles favourably comparable to those seen in adult or cisgender groups undergoing analogous breast procedures.

Psychosocial outcomes are 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.

Regret is rare, even in the longer-term follow-up studies that are available.

Non-medical gender-affirming practices
Evidence on non-medical practices such as binding, tucking, packing, and padding is limited but indicates that these practices help many TGD adolescents manage dysphoria and navigate daily life, particularly where access to medical care is limited.Packing and padding are low-risk, while discomfort from binding and tucking is common but typically manageable with safer materials, rest periods, and clear guidance on warning signs.Clinicians should be familiar with these practices and provide non-judgemental, practical advice, including exploration of options for medical GAHC when indicated.

Evidence on non-medical practices such as binding, tucking, packing, and padding is limited but indicates that these practices help many TGD adolescents manage dysphoria and navigate daily life, particularly where access to medical care is limited.

Packing and padding are low-risk, while discomfort from binding and tucking is common but typically manageable with safer materials, rest periods, and clear guidance on warning signs.

Clinicians should be familiar with these practices and provide non-judgemental, practical advice, including exploration of options for medical GAHC when indicated.

Policy and legal interventions:
Restrictive or hostile policy environments – including healthcare bans, administrative barriers, and exclusionary school policies – correlate with measurable increases in distress, self-harm, suicidality, social withdrawal, disrupted care, and family strain among TGD youth.Conversely, protective policy frameworks such as anti-discrimination regulations, legal gender recognition pathways, and inclusive school protocols are linked with improved mental-health outcomes, reduced risk behaviours, and enhanced wellbeing.These findings demonstrate that healthcare outcomes are shaped not only by clinical interventions but also by the broader social, legal and institutional conditions that enable or obstruct access to affirming care.

Restrictive or hostile policy environments – including healthcare bans, administrative barriers, and exclusionary school policies – correlate with measurable increases in distress, self-harm, suicidality, social withdrawal, disrupted care, and family strain among TGD youth.

Conversely, protective policy frameworks such as anti-discrimination regulations, legal gender recognition pathways, and inclusive school protocols are linked with improved mental-health outcomes, reduced risk behaviours, and enhanced wellbeing.

These findings demonstrate that healthcare outcomes are shaped not only by clinical interventions but also by the broader social, legal and institutional conditions that enable or obstruct access to affirming care.

The majority of studies were small and observational, constraining causal inference and precision.

Short follow-up periods limit understanding of long-term outcomes.

Samples seldom reflected South Africa’s population in terms of race, socio-economic status, disability, neurodiversity, and rural/urban distribution, and no eligible primary studies from the Global South or South Africa were identified.

Variability in outcome measures reduced comparability across studies, and rapid-review streamlining (including single-reviewer screening for some stages and limited grey literature searching) may have led to some missed or delayed records.

Despite these limitations, the consistency of findings across study designs, populations, and regions strengthens confidence in the overall conclusions.

Clinical practice:
Affirmation is central to safe and effective care, reflecting both clinical evidence and South Africa’s rights-based obligations.Multidisciplinary, coordinated teams that include supportive families improve outcomes across medical and psychosocial domains, and strengthen continuity and safety.Delays arising from policy and administrative barriers, resource shortages, or lack of trained providers worsen youth mental health and constitute avoidable harm; they should be reduced wherever possible.Psychosocial support, including that provided by families and caregivers, should be integrated across all aspects of care, including assessment, initiation of desired treatment, and ongoing follow-up, with supportive management of co-occurring mental-health conditions rather than their use as reasons to delay care.Menstrual suppression and fertility counselling should be offered proactively as part of comprehensive, developmentally appropriate, patient-centred sexual and reproductive health care when indicated or requested.Clinicians should adopt neurodiversity-informed approaches to meet the needs of TGD youth who are autistic, ADHD, or otherwise neurodivergent, recognising that neurodivergence is not a contraindication for GAHC.Surgical pathways require structured preparation, psychosocial support, and equitable access, with attention to the psychological impacts of long waitlists and provincial disparities in availability.Structured caregiver engagement is essential, as affirming families and caregivers are consistently linked with improved mental-health outcomes, sustained engagement in care, and enhanced daily functioning.

Affirmation is central to safe and effective care, reflecting both clinical evidence and South Africa’s rights-based obligations.

Multidisciplinary, coordinated teams that include supportive families improve outcomes across medical and psychosocial domains, and strengthen continuity and safety.

Delays arising from policy and administrative barriers, resource shortages, or lack of trained providers worsen youth mental health and constitute avoidable harm; they should be reduced wherever possible.

Psychosocial support, including that provided by families and caregivers, should be integrated across all aspects of care, including assessment, initiation of desired treatment, and ongoing follow-up, with supportive management of co-occurring mental-health conditions rather than their use as reasons to delay care.

Menstrual suppression and fertility counselling should be offered proactively as part of comprehensive, developmentally appropriate, patient-centred sexual and reproductive health care when indicated or requested.

Clinicians should adopt neurodiversity-informed approaches to meet the needs of TGD youth who are autistic, ADHD, or otherwise neurodivergent, recognising that neurodivergence is not a contraindication for GAHC.

Surgical pathways require structured preparation, psychosocial support, and equitable access, with attention to the psychological impacts of long waitlists and provincial disparities in availability.

Structured caregiver engagement is essential, as affirming families and caregivers are consistently linked with improved mental-health outcomes, sustained engagement in care, and enhanced daily functioning.

Policy and health systems:
Restrictive policies including administrative hurdles, opaque referral structures, or exclusion from medical-aid benefits cause measurable harm.Protective policies strengthen wellbeing at population level by reducing distress and suicidality, supporting resilience, and lowering demand on mental-health and emergency services.Health systems must address stock-outs, long waiting lists, and uneven provincial distribution of expertise, as these system-level barriers shape treatment trajectories, contribute to avoidable distress, and leave many adolescents without feasible routes into care.Equitable financing mechanisms are needed; current medical-aid exclusions disproportionately harm economically marginalised families and entrench inequities across provinces, sectors, and socioeconomic groups.Financing reforms should support multidisciplinary teams; reliable access to puberty pausers, GAHT, and menstrual suppression within essential medicines frameworks; workforce development; and expanded public-sector surgical capacity. Routine monitoring of wait times and geographic service distribution is also essential.Strengthening adolescent-friendly services and integrated pathways aligns with national priorities in youth mental health, HIV/SRHR, and human-rights protections and enables many non-specialised components of gender-affirming care to be delivered within routine adolescent health and mental-health services.Timely access should be treated as a matter of health equity and cost-effective prevention, given the documented harms of delayed care and its downstream impacts on schooling, distress, and emergency mental-health utilisation.

Restrictive policies including administrative hurdles, opaque referral structures, or exclusion from medical-aid benefits cause measurable harm.

Protective policies strengthen wellbeing at population level by reducing distress and suicidality, supporting resilience, and lowering demand on mental-health and emergency services.

Health systems must address stock-outs, long waiting lists, and uneven provincial distribution of expertise, as these system-level barriers shape treatment trajectories, contribute to avoidable distress, and leave many adolescents without feasible routes into care.

Equitable financing mechanisms are needed; current medical-aid exclusions disproportionately harm economically marginalised families and entrench inequities across provinces, sectors, and socioeconomic groups.

Financing reforms should support multidisciplinary teams; reliable access to puberty pausers, GAHT, and menstrual suppression within essential medicines frameworks; workforce development; and expanded public-sector surgical capacity. Routine monitoring of wait times and geographic service distribution is also essential.

Strengthening adolescent-friendly services and integrated pathways aligns with national priorities in youth mental health, HIV/SRHR, and human-rights protections and enables many non-specialised components of gender-affirming care to be delivered within routine adolescent health and mental-health services.

Timely access should be treated as a matter of health equity and cost-effective prevention, given the documented harms of delayed care and its downstream impacts on schooling, distress, and emergency mental-health utilisation.

Findings from this rapid review demonstrate that gender-affirming healthcare for TGD youth is evidence-informed, improves wellbeing, prevents harm, and supports healthier developmental and mental-health trajectories when delivered within supportive social, familial, clinical, and policy environments. The review reinforces the foundations of the existing South African GAHC Guideline and identifies opportunities to strengthen its implementation within South Africa’s legal, historical, and health-system context. While most available studies are observational, this reflects ethical and methodological realities of paediatric research and interventions that cannot be ethically randomised or withheld; consistent findings across diverse settings provide compelling, real-world evidence of effectiveness and safety.

Ultimately, this work reflects South Africa’s constitutional values: dignity, equality, and the right to access healthcare without discrimination. South Africa has a longstanding tradition of protecting the marginalised, guided by principles of collective care and justice, and ensuring affirming, timely care for TGD youth is both clinically sound and a continuation of that legacy, and a commitment to safeguarding the wellbeing of every young person entrusted to collective care.