July 28, 2025 • 56 mins
Content note: This episode references transphobic arguments and objections to gender-affirming health care (GAHC) in our discussion and explanation of the guidelines for GAHC. If you’re unable to engage with these topics right now, you are welcome to skip this episode or come back to it when you feel better resourced.
This episode kicks off a multi-part series on the health of trans and gender-diverse (TGD) communities in South Africa. Dr Anastacia Tomson — medical doctor, activist, and lead author of South Africa's groundbreaking gender-affirming healthcare guidelines — joins us to dispel myths, clarify misconceptions, and highlight the life-saving importance of evidence-based, compassionate care.
Connect with Anastacia📸 @anaphylaxus
🌐 myfamily.gp
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⏳ Chapter timestamps00:00:00 Land acknowledgement
00:00:28 Title credits
00:00:43 Health disclaimer
00:01:38 Welcome and introduction
00:05:11 About the work of Dr Anastacia Tomson
00:11:16 The real values underpinning gender-affirming health care (GAHC)
00:19:27 The actual access to GAHC
00:23:32 Gender-inclusive language 101
00:27:01 Non-medical gender-affirming practices
00:33:23 What is hormone therapy actually?
00:41:38 What is gender-affirming surgery actually?
00:50:59 A future for everyone
00:56:17 End credits
📌 Featured ResourcesTomson, A., McLachlan, C., Wattrus, C., Adams, K., Addinall, R., Bothma, R., Jankelowitz, L., Kotze, E., Luvuno, Z., Madlala, N., Matyila, S., Padavatan, A., Pillay, M., Rakumakoe, M., Tomson-Myburgh, M., Venter, W., & de Vries, E. (2021). Southern African HIV Clinicians Society gender-affirming healthcare guideline for South Africa. Southern African Journal of HIV Medicine, 22(1). https://doi.org/10.4102/sajhivmed.v22i1.1299
Tomson, A. (2020). Always Anastacia. Jeppestown: Jonathan Ball Publishers.
📚 ReferencesMcKinney, A. Among the Stars, no piano edit. ZapSplat. https://www.zapsplat.com/music/among-the-stars-no-piano-soothing-ambient-choir-portrays-panoramic-space-good-for-landscapes/
Miles, D. Shades of Orange. ZapSplat. https://www.zapsplat.com/music/shades-of-orange-a-serene-relaxing-warm-ambient-piece-with-slow-mellow-chords-perfect-for-relaxation-meditation-etc/
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Aurora Brown and Intersectional Psychology acknowledge the traditional owners and custodians
(00:08):
of country throughout South Africa, and their connections to land, water and community.
We pay our respects to their elders past and present, and extend that respect to all Indigenous
people listening today.
(00:30):
This episode is for educational purposes only, and is not intended to be a substitute for
(00:51):
professional health advice, diagnosis or treatment.
Aurora Brown and Anastacia Tomson are not able to answer specific health questions about
individual situations.
Always seek the advice of your health provider with any questions you may have regarding
(01:14):
your health care and health conditions.
Never disregard professional medical advice or delay in seeking it because of something
you have heard or seen on this podcast.
If you think you need immediate assistance, please call your local emergency number or
(01:35):
any mental health crisis hotline.
Hello and welcome back to Intersectional Psychology, the podcast that explores psychology's role
in promoting social justice.
I'm your host, Aurora Brown, I'm a Registered Counsellor in Cape Town, South Africa.
(01:57):
Thank you for being here, how are you and what is happening in your world?
Today we are kicking off a multi-part series on the health of people who are trans and
gender diverse, or TGD for short.
Gender diversity has been part of the human story for as long as we've had stories
(02:21):
to tell.
One of the earliest recorded trans figures in history is the Roman Emperor Elagabalus,
who lived nearly 2000 years ago and is said to have asked to be called a woman and even
sought gender affirming surgery.
(02:41):
And across cultures throughout history, there have been numerous examples of gender diversity
and gender non-compliance even before that.
But until very recently, most cisgender people didn't give trans lives much thought at all,
(03:04):
unless they actually knew a trans person personally.
Now gender affirming healthcare is a term that's on everyone's lips, and apparently
everybody has an opinion about it.
But here's the real question.
(03:24):
How many people actually know what gender affirming healthcare really is?
What does it entail?
How does it impact the lives of trans people?
And then there's the question that somehow always gets framed as the most important.
(03:44):
How does it impact cis people?
Spoiler alert, not nearly as much as they think.
So to help us separate fact from fearmongering, I am deeply honoured to host someone who is
quite frankly one of the most qualified people in South Africa to speak on this topic.
(04:10):
Dr Anastacia Tomson is a medical doctor, an author, and a fierce advocate for LGBTQIA+,
and human rights.
She was the lead author of the inaugural and still the most comprehensive guideline for
gender affirming healthcare in South Africa.
(04:33):
Her lived experience as a queer, transgender woman who transitioned within South Africa's
healthcare system, combined with her years of clinical work supporting others on their
own journeys, gives her a rare and invaluable perspective.
Her work is driven by a deep well of compassion and a fierce commitment to justice.
(05:00):
Anastacia, welcome to the podcast.
Hi, it's my pleasure and privilege to have this conversation with you today, Aurora.
(05:22):
What can we know about you and your work?
I kind of hate talking about myself and listening to the intro that you gave a few minutes
(05:47):
ago.
That just sounds to me like, wow, those are some big shoes to fall, and I wonder who that
person is.
So, I don't always feel like that Anastacia, but to put it in very simple and I'm going
to try humble terms, I am a primary care provider, a GP, working in a remote fishing village outside
(06:09):
of Cape Town that some of your listeners might have heard of.
It is called Sea Point, and I treat LGBTQIA+ patients, I mean, I treat everyone, but
I certainly have a special interest in treating LGBTQIA+ patients.
I provide a lot of gender affirming healthcare services and manage the hormone therapy for
(06:32):
a lot of trans folk.
In addition to that, I do a bunch of work with, let me say, patients who've experienced
medical trauma over their tricky health conditions like fibromyalgia or parts or connective tissue
disease or et cetera, et cetera, et cetera.
(06:55):
The kind of conditions where you go to the doctor and they don't believe that you have
pain or they look at the labs and say that you're fine or ready where they just tell
you, oh, go lose weight kind of thing, and that will solve all your problems.
So those are the kind of things that I do.
And then in addition to that, I do the occasional bit of activism, which whether or not it's,
(07:18):
I don't know if it's opt in or opt out at this point, we can have another conversation
about consent sometime down the line.
And I do a bit of teaching with medical students at UCT.
Thank you.
I think I would have loved to be one of your students.
(07:40):
I've attended some of your talks and you have a wonderful sense of humor and a talent for
making complicated subjects seem very clear and simple.
How did you come to be involved in this work?
How did you come to serve this community?
Accidently.
(08:00):
I was working in clinical research elsewhere in Cape Town.
It was the first job that I took when we moved to Cape Town.
It was actually the reason that we moved to Cape Town,
my wife and I.
So I was working in clinical research and the company that I was working with landed
(08:21):
on some difficult times, and I resigned and looked for some primary care work in the neighborhood
that we at that point lived in, which was Sea Point, and I found a practice who was looking
for another doctor to come on board and I did so.
(08:42):
And at that point, moving forward, you know, I've, so since the beginning, I have learned
through my own medical trauma that it's very difficult to rely on other people to manage
my own hormone therapy.
I did everything by the book.
Initially, I have the scars from that, you know, those wounds still, still hurt me and
(09:04):
make it difficult to seek my own health care.
And I learned from those experiences now almost a decade ago that if I want to to be cared
for in the best possible way, I've got to do it myself.
So I had the knowledge or at least I had the, you know, I built up the experiential sort
(09:25):
of.
Yeah, education, the, the learn it by doing it sort of thing and learn it by living it.
And I also have always had that moment of reflection where I think well, if I struggle
like this as someone who has an actual medical degree, then what about the people who don't,
(09:50):
which in this country happens to be the majority of trans people who aren't walking around with
medical degrees and prescribing rights.
And I thought, well, that must be a pretty shit experience.
So sorry, am I allowed to swear?
Okay, great.
Got the thumbs up.
So I thought that must be a pretty shitty experience.
And I started offering these services because I mean, no one else would.
(10:15):
And it was just part of what I do is a much smaller part of what I do.
I would say that by now sort of five years later, five and a bit years later, the kind
of specialized work or the niche work that I told you about occupies about 85% of my
(10:35):
clinical time.
So certainly it's grown.
And yeah, that's sort of I didn't set out and say I'm going to be the hormone
doctor.
It just kind of happened that way.
(11:06):
Now, the reason we are here today are the guidelines around gender-affirming health
care.
The South African HIV Clinician Society's gender-affirming health care guideline, which
(11:26):
was published in 2021, is the gold standard for gender-affirming health care in South
Africa.
And it is the most comprehensive and evidence-based set of guidelines for trans health care.
This guideline has been endorsed by a variety of professional and civil society organizations
(11:50):
including the Professional Association for Transgender Health South Africa, the Psychological
Society of South Africa, the WITS Reproductive Health and HIV Institute, the University of
Pretoria's Center for Sexualities, AIDS and Gender, GenderDynamix, Triangle Project
(12:13):
and Be True 2 Me.
You were the lead author of these guidelines, so I can't think of anyone better to talk
about gender-affirming health care.
Now, I believe the guideline was informed by the World Professional Association of Transgender
(12:34):
Health Guidelines, but also adapted and decolonized for the South African context?
WPATH and their guidelines have been around for a long time.
It's called Standards of Care.
It dates back at some point before it was called WPATH.
It was called the Harry Benjamin Institute for...
I don't even want to go there.
(12:55):
There has always been some clinical guideline for the management of trans folks to whatever
extent.
The problem is that these guidelines are developed in and for the Global North and trying to adapt
them to sociocultural situations that are very different to that isn't always easy.
(13:21):
They'll talk about medications and treatments and tests and investigations and things that
we just don't have.
They have resources to the health care system that we just don't have.
We need to find solutions that make sense in this context.
You can't scale it in that sense because it's apples and oranges.
(13:46):
In developing the guidelines, we drew on a wealth of published scientific evidence,
not just the WPATH guidelines, but we really did a very, very, very, very comprehensive
literature review to inform a lot of what we were suggesting in the guidelines.
(14:08):
Throughout that process, we understood that localizing this and giving ownership to this
community here in South Africa for whom we're writing this and recognizing that probably
it will be adapted or have some relevance would be drawn on elsewhere in Africa, particularly
(14:33):
in our neighboring countries.
We had that in mind and we really tried to involve firstly a multidisciplinary team,
so it wasn't just doctors or endocrinologists or psychiatrists, but we really tried to bring
in people from a variety of different professions.
We had psychologists, we had dietitians, we had speech therapists, weighing in on all
(14:56):
of this.
We also looked at social policy and institutional policy, what happens in hospitals, what happens
in prisons, what happens in clinics in terms of handling all of this.
We tried to take this holistic view and by assembling as diverse as we could a team of
(15:18):
authors and also recognizing that this guideline was not ever intended to be the final gospel
truth on gender-affirming care intended to be a first step and knowing that things will
change and that there will be, ideally, you know, there will be new iterations just like
(15:39):
there are with the standards of care, then this was us trying to do right by the community
in as many ways as we possibly could and that was really important to us.
And yet despite all of this evidence and all of the many years of clinical trials and research
(16:02):
reports, the gender-affirming approach is still criticized by some as, quote-unquote,
“gender ideology”.
What are the values that really underpin this guideline?
I think the primary value is just respect for individual autonomy.
(16:24):
You know, we speak about in the guidelines, we say what are the indications for gender
reform and hormone therapy, you know, and number one is that you need to want the treatment.
Number two is that you have gender incongruence and number three is that you are capable of
making a decision.
(16:45):
So the entire power of decision-making as it should be in healthcare rests with the individual
who's accessing services.
Our job isn't to make the decision on anyone's behalf.
I can't say yes, no, here’s your hormones, you don't get hormones, you must have hormones,
(17:08):
I don't get to do that.
I have to use my knowledge training, expertise, experience, skills in order to take the encyclopedic
knowledge that I have around the human body and pharmacology and physiology and all of
that and pick out the little bits that relate to gender-affirming hormone therapy and present
(17:34):
them to, I use “patient”, to present them to the patient in a way that they can understand
and that they can interpret so that they can make a decision that is the best decision for
them at that point in time.
So the value for me that underpins and I mean you can go read the guidelines, they're open
(17:58):
access and peer-reviewed, but they are open access and you can go read in the preamble some of
the values that we as a team have said underpin the guidelines and we do stick to them.
I think for me the most important thing was always going to be respect for autonomy.
Everything that we've done is informed by an approach consistent with medical ethics
(18:19):
which is something else that I've published on in the past.
So we continue to do that and as is ethical and as is in HPCSA and as we are all taught
we should be working on an informed consent basis where people are permitted to have agency
over their own bodies and as you can imagine, not even imagine but as you well know in 2025
(18:46):
in the climate that we live in, even in the Global North or maybe even more so in the
Global North this concept is becoming very, very politicized.
(19:08):
The truth about the access to gender-affirming health care.
Now before we dive into what gender-affirming health care actually comprises, let's talk
(19:31):
about how someone would access gender-affirming health care.
What is the process for an adult to follow before they can begin receiving gender-affirming health care?
So obviously that process is going to differ depending on where you are and on where you're
accessing your services.
So you know I speak about where you are in terms of geography and where you're accessing
(19:55):
services in terms of primary, sorry public versus private and also at which level you
know as a primary, as a secondary, as a tertiary etc.
We, our guidelines and international guidelines are promoting the idea that gender-affirming
(20:15):
care should be available at a primary care level, that it doesn't require necessarily
specialist initiation or intervention.
It isn't yet easily accessible in the public sector in South Africa at a primary care level,
especially now that a lot of the NGO public sector partnership clinics that were providing
(20:39):
the service at primary care are no longer funded, so that does become a little bit tricky.
At this point a patient would have to present to their primary care provider and request
a referral to the transgender clinic for example at Groote Schuur.
This process will look different depending on where in South Africa you are and in some
(21:01):
areas like Limpopo or this might be almost impossible, so it's very very difficult potentially.
It does get a little technically easier in the private sector if you are able to see
a provider who is informed and knowledgeable about the provision of gender-affirming care
(21:24):
or who is willing to learn and who's willing to prescribe the treatment for you, then you
know you would be able to make an appointment with that person, ideally this is what would
happen if you were seeing me and that person would probably give you the information ahead
of, I would give you the information ahead of time to read up a little bit about the
hormones, this would be information that I have personally sourced and vetted and that
(21:46):
I will vouch for as being accurate, there's great information on the internet and there's
also not so great information on the internet, so I would give you that ahead of time.
Some patients would want to do their baseline laboratory investigations ahead of time, so
maybe go and do some blood tests, you would sit with me and we would go through what are
(22:07):
your options, what does it look like, what are the pros, the cons, the risks, the benefits,
the side effects, the consequences, the costs, etc, we go through all of it together, you'd
have ample opportunity to ask questions, we would do a physical examination for you and
then we would collaborate in terms of the decision making on what is the route forward,
(22:28):
are you starting on hormone therapy, when are you starting on hormone therapy, what
kind of hormone therapy are you starting on, so that's kind of what the process would
look like in in private or in an ideal world that is just what the process would look like,
Thank you.
Thank you.
(22:57):
Gender inclusive language 101
The guideline includes some very useful tips on gender inclusive language for practitioners
(23:20):
to use when taking asexual history, but I also think many of these tips would be helpful to
every person listening to this who doesn't regularly interact with gender queer folks.
Which of these tips would you like to share here?
So I think it starts with like, let's not make assumptions about what kind of people are in
(23:43):
what relationships with what other kind of people and what kind of intercourse that they're having,
so you know, it's language like partner instead of boyfriend, girlfriend, husband,
wife, etc, I think it's also important to recognize that people might have multiple partners
and that those partners could be regular partners or they could be sporadic partners,
(24:06):
just making space for people who are potentially polyamorous.
I think it's important for us to find language that is disarmed in terms of referring to anatomy
and body parts, and I think the best way to do this is just to have a conversation either with
the patient or with your partner, depending on whether you are a clinician or someone who's just
(24:30):
getting something nice to find out, you know, how would you like me to refer to this? Is there
any language that you would prefer me to avoid or, you know, a lot of it is just
let's not make assumptions. So, you know, again, let's not lean into like the heteronormativity,
but let's also just recognize that I can't know what's good and right for you,
(24:56):
unless I ask you. And I think maybe here's the number one tip, it's really just this,
is don't be afraid to talk about it. You know, we all are indoctrinated with this ideology
that sexuality is a taboo and that we're not allowed to talk about it. And, you know,
(25:20):
we've, I've discovered one thing is that if you do talk about it, the world doesn't end and
things are actually better for it. So, you know, maybe that's the tip is just practice talking
about it, go look in the mirror and have the conversation with yourself first.
Non-medical gender affirming practices
(25:48):
You mentioned that there is a lot of misinformation about HIV and TGD people out there. There's also
(26:11):
a lot of misinformation and disinformation, even in the media, about other aspects of gender
affirming healthcare, like hormone therapy and surgery. But there are actually also many
non-medical gender affirming practices that many TGD people start with before or even instead of
(26:35):
hormonal or surgical transition. Could you tell us a bit more about these non-medical
gender affirming practices? Yeah, I can and I can tell you that a lot of people start with them
long before medical or surgical intervention. I can tell you that some people start with them
long afterwards and some people start with them at the same time and some people never do them.
(26:57):
And the reason I'm saying all of this is just to reinforce and reiterate the idea that no
two transitions look alike. The roadmap doesn't exist. So, you know, I want to say it's different
for everyone, but it actually just doesn't exist. And no singular transition is more or less valid
(27:17):
than another one for what it does contain or doesn't contain or when it contains it.
And it's for this reason that I refrain from using language like full transition,
even if we're talking about hormone therapy doses, we don't talk about a full dose because that
implies that someone who's on a low dose or someone who's micro dosing is somehow less than. So,
(27:39):
I really don't want to do that. And, you know, it just comes to mind when we say this. But
transition can be so many different things. And, you know, we can divide it up. So, to me,
there are medical interventions. There are surgical interventions. But people can transition legally by
updating their documents. People can transition socially by changing the way that they dress or
(28:02):
using a different name or pronouns. People can pursue things like laser hair removal or
electrolysis or voice training or bodybuilding. You know, each and every one of these can be
gender affirming. And sometimes it is breaking the rules that are associated with gender,
(28:23):
that is actually gender affirming. So, there are so many different ways that people might
affirm their gender. And for some people, it might be binding, you know, putting on a thick
or elastic garment that flattens breast tissue to give the appearance of a more masculine chest
(28:44):
or might be tucking where the external genitalia are folded up in such a way as to render them inconspicuous
in even very revealing clothing or swimwear. But not everyone is going to do this. Not everyone
should have to do this. There shouldn't be a responsibility on anyone to do this. But really
(29:05):
what I'm just trying to illustrate is that, you know, this is a kaleidoscope. I mean,
what I find gender affirming and what you find gender affirming could be very different. So,
we need to really take a much broader look at what gender affirmation is. And cisgender people
do it too, you know. I mean, cisgender men use testosterone or they have treatment for
(29:32):
alopecia or, you know, cisgender women who have augmentation, mammoblasties or face,
that's all gender affirmation because we see these things through a gendered lens. So, you know,
the idea that we could reduce it into these like medical minutiae when the entire concept of
(29:52):
gender affirmation is actually rooted in social structure. And I'm not going to say gender is a
social construct because things are much more nuanced than that. And please, let's not go there.
But, you know, to realize that like makeup, for example, is inherently not a gendered item.
But we insist on seeing it in a gendered way, you know. And so, recognizing that I think the
(30:19):
framework of what constitutes gender affirmation and what practices are gender affirming can be
very, very different for everyone. And this is why reducing or minimalizing this lens that we
consider care, and I'm not going to say healthcare, but I'm going to say care for trans and gender
(30:43):
diverse people to this narrow focus of hormones and surgery, like that really isn't enough, you
know, we should welcome at the clinic, we should welcome people to use the bathroom or the restroom
with which they identify, but we should also provide a neutral space for people who aren't
(31:05):
comfortable in either of those spaces. You know, and it doesn't mean now you have the men's room,
the women's room, and the trans' room that all of the trans' must go to, you know, it's not like
that. But it's really about just figuring out what are the things that are acting actively to
dismantle affirmation, and how do we deal with that. So, you know, I've given you a very broad
(31:30):
and ethereal answer to this question, but I think it almost necessitates that.
Hello, it's me, Aurora. Please excuse me interrupting my own podcast. I'm just here to say that I will
(32:00):
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Psychology. Thanks and back to Intersectional Psychology.
(33:34):
The Truth About Hormone Therapy
Now, we get to one of the contentious areas of gender-affirming healthcare,
(34:08):
hormone therapy. So, to start with, what should we know about HT in general?
What you should know about hormone therapy is that all human bodies have, at a baseline,
some oestrogen and some testosterone in varying degrees, but these are both molecules,
(34:28):
substances, let's stick with molecules that are intrinsic to the human body. They're not foreign,
they're not outside elements, they're not these synthetic, dangerous chemicals that people might
make them out to be, and that many of the drugs that we use to treat other conditions actually are.
We are tinkering with the balance between oestrogen and testosterone, but we're doing so
(34:53):
using those exact same molecules and hormones that your body already produces.
And then the other thing to bear in mind is just that we are not trying to do anything that is
beyond physiological limits. So, you know, the body is capable and programmed to and is happy
(35:14):
in certain ranges with these hormones, and this is what we're trying to do with gender-affirming
hormone therapy. So, if you're coming on, you're going on testosterone therapy, I'm not trying
to give you Arnold Schwarzenegger doses of testosterone, I'm trying to give you physiological
doses of testosterone. When is hormone therapy prescribed and when isn't it?
(35:41):
When is hormone therapy prescribed? When someone wants hormone therapy, when they are gender incongruent,
and when they are capable of giving consent, sorry, that's only three things. That is when
hormone therapy is prescribed. There are very, very, very few of what we would call absolute
contraindications to hormone therapy cases where I absolutely cannot give hormone therapy, and that
(36:04):
would be things like if someone has a cancer that is sensitive to one of the hormones, like an
oestrogen-sensitive cancer, if oestrogen is the growth factor, I'm of course not going to give that
person oestrogen. If it's someone who's had a venous thromboembolism or who has a familial
clotting disease, then that could be an absolute contraindication. But other than that, we have
(36:29):
relative contraindications, areas where we have to exercise a little extra caution, not that we
don't exercise the utmost of caution anyway, which we do, and then we have coexisting conditions that
need to be managed alongside. So, high blood pressure doesn't mean you can't have hormone
therapy until you get below a certain measurement, but it does mean that I'm going to manage it at the
(36:54):
same time. Feminising and masculinising hormone therapy is obviously quite different and has
different effects. What should we know about feminising hormone therapy? Feminising hormone
therapy, the specifics can be a little bit different, depending on the case, but the backbone
(37:16):
of it is oestrogen. What we're trying to do with the administration of oestrogen is to promote the
development of what we would call female secondary sexual characteristics, so things like the growth
of breast tissue, things like body fat distribution, things like changing the texture and the oiliness
(37:37):
of skin, things like promoting growth of scalp hair. These are the sort of things that we would
expect from feminising hormone therapy. And how does masculinising hormone therapy work?
Masculinising hormone therapy, the backbone in this case would be testosterone, and we would be
(37:58):
promoting virilisation, which is the increase of muscle mass, it would make the skin oilier,
we would see growth of facial hair, we would see thicker, courser body hair, we would see
probably an increase in libido, we would see an increase in metabolic rate and that sort of thing.
We would also see what we call bottom growth or hypertrophy of the clitoris, and in some instances
(38:24):
we would see the cessation, i.e., it would stop cyclical bleeding.
Now, if someone has already gone through endogenous puberty, there are some effects
of that puberty that can't be reversed through hormone therapy.
What are some of the impacts of puberty that hormone therapy can't change?
(38:48):
What's important to understand here is that hormones, sex hormones, oestrogen and testosterone
have two kinds of effects. They have effects that are reversible and effects that are irreversible.
And this is true whether we speak of exogenous hormones, that means the ones that you buy in the
bottle or endogenous hormones, that means the ones that come out of your body. All of them have
(39:11):
both of these kinds of effects. Testosterone, for example, has a lot more irreversible effects
than oestrogen does, and if someone went through puberty and they were exposed to these high
levels of testosterone, they would have developed some of these irreversible effects of testosterone,
such as the growth of facial hair, such as the thickening of the vocal folds, which causes
(39:32):
someone's voice to drop. Potentially, androgenic alopecia, male pattern baldness, could be irreversible
if it's persisted for long enough. That's the effect of testosterone and its metabolites
on the hair follicles themselves. So these are irreversible effects that we talk about,
(39:53):
and someone who's been exposed to endogenous hormones will experience those. Then on the
other hand, if we speak about oestrogen, what are irreversible effects of oestrogen? Well,
that would be the development of breast tissues. So I'm talking here about structural
breast tissue glands and ducts. If there's fat in breast, which there is, some of that might
(40:14):
distribute away and they might get smaller, but the growth of breast tissue. So if you've gone
through a puberty and you've developed D-cup breasts, those aren't going to go away,
unless something else is done. And then of course, we just have to consider when it comes to things
like skeletal growth and dimensions. So the hormones do have an effect ultimately on how
(40:41):
you grow and for how long you will grow and in what ways you will grow in the shape of bones
and things like that, which are irreversible not by virtue of the hormones, but by virtue of time.
So would it be fair to say that as a TGD person starting hormone therapy,
(41:02):
you're basically experiencing a second puberty? And all of those changes that are irreversible
in endogenous puberty would then also be irreversible after taking hormone therapy?
Yeah, I think it would be unfair to say it, but 100% true. You are going through a second puberty,
(41:22):
and if it was difficult the first time, try doing it when you understand what's going on and how the
world around you works. And you've actually got that sort of lived experience and that wisdom
to then go through a period where your skin becomes oily and pimply and your voice is breaking and so
on. But yeah, the irreversible changes would occur in a second puberty as well. And that's
(41:46):
what we expect to see in people who are going on exogenous hormone therapy.
(42:17):
And now let's talk about surgery. Before we get into specifics, what background information should
we know about gender affirming surgery? I think what we should know is that this is often a facet
of trans experience that the cisgender majority wants to focus on and zoom in on and it attracts
(42:41):
all kinds of just attention and it's almost seen as this is what trans identity is about,
is the sex change operation. And what I think is very important to realize is just that
of trans people who want gender affirming surgery, which is not all of them and doesn't have to be
(43:03):
all of them and no trans person is less valid because they don't want surgery or they don't get
surgery, it is a fraction of people who will actually have access to those procedures.
And so much of trans lived experience is non-surgical, not to say that surgery can't play
a role in it, but just that it's non-surgical. And even to say that surgical experience doesn't
(43:28):
occur in isolation because there's so much that goes on around it that is non-surgical. So to get
lost in that conversation is very unhelpful. If you want to understand trans people better to
have another pin on your ally flag, then don't start by reading up on surgery, it's not going
(43:49):
to get you there. And certainly don't go around and ask your token trans friends about the
surgeries that they've had or the surgeries that they want. There is so much, so much,
so much more to this. The surgeries can be very interesting in terms of anatomy and technique
and so on. Particularly if you do have an interest in surgical, I find it very fascinating to understand
(44:17):
what procedures are being done and how they're being done and what new techniques are being
developed. But that's an interest that's born out of my sort of fascination with surgery in
general and not out of my obsession with what's inside people's pants.
Thanks. As you say, a fraction of trans people who want surgery actually have access to it,
(44:44):
especially here in South Africa. I think in the Western Cape there are only one or two gender
affirming surgeries performed per year in the public sector. And I know that trans people who
inquire about it are told the waiting list for gender affirming surgery here is about 15 years
(45:07):
in the public health system. So it's really not everyone who is going to have such surgeries.
Not everyone wants it and even fewer people have access to it.
And when is surgery prescribed and when isn't it?
The first thing about the surgery, the surgery about surgical intervention is that you need to
(45:31):
want it. I'm not going to name names, but I believe that there are certain gender clinics that
have been in operation in South Africa that had patients sign a contract before they went on
hormone therapy saying that they will at a later date have surgery. We don't do that. We shouldn't
do that. It's an individual choice. It can affect so many different things in so many different
(45:57):
ways. There's healing time, there's complications, there's all sorts of things that go into it.
So who gets surgery, someone who wants surgery, someone who is capable of making that decision,
there is often going to be a requirement for at least an interaction with the mental
healthcare provider who's of suitable qualification to ensure that a patient is competent to make the
(46:22):
decision. So there's still that little bit of gatekeeping involved. And I think it's also
important to realize that surgery isn't enough on its own. I see patients coming in through my door
who had gender-affirming surgery 25 years ago. And since then, no one so much as prescribed
a hormone for these people. They've been walking around with zero testosterone, zero oestrogen,
(46:44):
increasing their risk for osteoporosis, for fractures, for heart disease, for depression,
for all kinds of things. So it's not like you put people on the assembly line and you do surgery
and then off they go. And further to that, it's got to be people who we always consider surgical
risk and the benefit. And someone who is a good candidate for surgery will be someone who is what
(47:09):
we term an aesthetic risk or risk of complications related to other medical conditions is as low
as possible. That if there are other conditions that they've been optimized, that this is someone
who's going to be able to adequately recover and to go through all of the procedures that are
associated with that. Sometimes there's like a little bit of like maintenance that needs to be
(47:31):
done. And you know, it's not something to be taken lightly. But if someone expresses this
persistent desire for a certain procedure, you know, and then we've had the conversation with
them, the informed consent, we've managed the expectations, you know, surgery is never going
to be a silver bullet. It could be that you have intense dysphoria over certain parts of your anatomy
(47:55):
and you will never have that dysphoria adequately relieved without surgery. But you will not
necessarily just need the surgery in order to feel better. So, you know, it's in that case,
it could be necessary, but not sufficient, if that makes some sense. So these are the considerations
around, you know, we don't prescribe surgery, we collaborate with people on a decision, and
(48:24):
then we try to get them access to the interventions that they want or need, and to do so in a way
that is safe and responsible and scientifically sound.
(48:59):
As we wind up this episode, would you like to share what is on the horizon for you?
Not really anything that I can very directly plug. Just to say that there are some exciting things
happening in terms of rolling out at least training on gender-affirming health care
at the primary care level. I don't know how much detail I'm allowed to give on it, so I'm not going
(49:23):
to. And then to say just on an individual or not an individual level, but at least
part of the, on the level of the team and the practice that I run, is just that we are looking
at some ways to actually do some research into the role of narrative agency in a health care,
which I think is very important for both patients and for providers, and that there's a whole lot
(49:46):
of interesting and intersectional conversation to be had around that, and the sort of colonialism
that remains inherent, and the patriarchy that remains inherent in medicine, and how we dismantle
that through voice, you know, whether it is spoken voice or written voice, et cetera.
So I find that to be intriguing, and if I can get funding to do the research, then certainly
(50:11):
I'll be blabbing about it a lot more. That sounds really exciting, and seeing as you didn't mention
it yourself, I'll just plug your book. It is for sale all over. I know Exclusive Books have it here
in South Africa, and it is also available internationally. Just search for “Always Anastacia”
(50:36):
by Anastacia Tomson. I loved reading it. I really enjoyed reading a positive representation
of a trans person in South Africa, and it is written with your usual eloquence and sense of humor.
Thank you. The book, I often forget to mention it because it's nine years old. It's almost going
(51:01):
to be able to go to school by itself, so I forget that it's a thing, and it just keeps coming back,
which I suppose is a good thing. But it also reminds me that I probably need to sit down
and write another one, and I don't know on whose time and on whose coin I'm going to do that,
so we're still trying to figure that out on ours.
Where can listeners go to find out more about you and your work?
(51:25):
For better or worse, I'm infinitely Google-able. The only trap door there is that you have to
spell my surname correctly. It doesn't have an H, and it doesn't have a P. You'll also find me all
over social media under the handle Anaphylaxus. That's got a U-S at the end, not an I-S at the end.
Again, it is a very deliberate and intended misspelling, so it's not really a misspelling, but
(51:49):
you'll find me all over social, and you can also read more about the work that we do at the practice
at myfamily.gp, if you so wish. Anastacia, thank you so much for your time and your insight,
and your extraordinary contributions to trans healthcare in South Africa.
(52:12):
You've not only helped demystify what gender-affirming healthcare actually is,
you've also reminded us that healthcare, at its heart, should be about care.
For anyone listening who thought gender-affirming healthcare was a niche issue or some kind of
(52:33):
political hot potato, today made it clear it's healthcare, full stop. It's evidence-based,
it is life-saving, and when it's done right, it can be profoundly affirming. Not just of gender,
(52:55):
but of humanity. And if you're still wondering how it affects cis people,
maybe it's this. The more we build systems that honour everyone's dignity, the better
they work for all of us. This was just the first episode in our series on the health of
(53:20):
trans and gender-diverse people. In our next installment, we'll be speaking to a mental
health professional about what an affirming therapeutic relationship really looks like,
and how to tell the difference between support and subtle sabotage. Until then, stay curious,
(53:42):
stay compassionate, and please don't believe everything you hear in the WhatsApp groups.
Thank you for listening to Intersectional Psychology. Please follow or subscribe to
the podcast to get every episode. If you enjoyed this episode, please rate and review
(54:04):
Intersectional Psychology in your preferred app. It really helps other people find the podcast.
This episode of Intersectional Psychology was researched, written, recorded, and edited
by me, Aurora Brown. For a transcript of this episode, please see the link in the show notes
(54:29):
on your podcast app, or go to intersectionalsychology.com. You can also check the website
or the show notes for a full list of references for this episode.
A video of this episode with closed captions is available on youtube.com forward slash
(54:51):
intersectionalsychology. To support this podcast and get access to bonus content,
including additional episodes and interviews, as well as more guided mindfulness sessions
please go to Patreon.com/IntersectionalPsychology. You can also chat
(55:14):
with me on BlueSky at intersectpsych.bsky.social and Instagram, Facebook, or TikTok at IntersectionalPsychology,
but mostly BlueSky.
Aurora Brown and Intersectional Psychology are committed to the Cite Black Women praxis.
(55:41):
All episodes of Intersectional Psychology are for educational purposes only and are not intended
to be a substitute for professional mental health advice, diagnosis, or treatment.
I, Aurora Brown, am not able to answer specific questions about individual situations.
(56:03):
Always seek the advice of your health provider with any questions you may have regarding a mental
health condition. Never disregard professional medical advice or delay in seeking it because
of something you have heard or seen on this podcast. If you think you need immediate assistance,
(56:24):
please call your local emergency number or any mental health crisis hotline.
Everyone deserves good mental health.
Aurora Brown and Intersectional Psychology acknowledge the traditional owners and custodians
(00:08):
of country throughout South Africa, and their connections to land, water and community.
We pay our respects to their elders past and present, and extend that respect to all Indigenous
people listening today.
(00:30):
This episode is for educational purposes only, and is not intended to be a substitute for
(00:51):
professional health advice, diagnosis or treatment.
Aurora Brown and Anastacia Tomson are not able to answer specific health questions about
individual situations.
Always seek the advice of your health provider with any questions you may have regarding
(01:14):
your health care and health conditions.
Never disregard professional medical advice or delay in seeking it because of something
you have heard or seen on this podcast.
If you think you need immediate assistance, please call your local emergency number or
(01:35):
any mental health crisis hotline.
Hello and welcome back to Intersectional Psychology, the podcast that explores psychology's role
in promoting social justice.
I'm your host, Aurora Brown, I'm a Registered Counsellor in Cape Town, South Africa.
(01:57):
Thank you for being here, how are you and what is happening in your world?
Today we are kicking off a multi-part series on the health of people who are trans and
gender diverse, or TGD for short.
Gender diversity has been part of the human story for as long as we've had stories
(02:21):
to tell.
One of the earliest recorded trans figures in history is the Roman Emperor Elagabalus,
who lived nearly 2000 years ago and is said to have asked to be called a woman and even
sought gender affirming surgery.
(02:41):
And across cultures throughout history, there have been numerous examples of gender diversity
and gender non-compliance even before that.
But until very recently, most cisgender people didn't give trans lives much thought at all,
(03:04):
unless they actually knew a trans person personally.
Now gender affirming healthcare is a term that's on everyone's lips, and apparently
everybody has an opinion about it.
But here's the real question.
(03:24):
How many people actually know what gender affirming healthcare really is?
What does it entail?
How does it impact the lives of trans people?
And then there's the question that somehow always gets framed as the most important.
(03:44):
How does it impact cis people?
Spoiler alert, not nearly as much as they think.
So to help us separate fact from fearmongering, I am deeply honoured to host someone who is
quite frankly one of the most qualified people in South Africa to speak on this topic.
(04:10):
Dr Anastacia Tomson is a medical doctor, an author, and a fierce advocate for LGBTQIA+,
and human rights.
She was the lead author of the inaugural and still the most comprehensive guideline for
gender affirming healthcare in South Africa.
(04:33):
Her lived experience as a queer, transgender woman who transitioned within South Africa's
healthcare system, combined with her years of clinical work supporting others on their
own journeys, gives her a rare and invaluable perspective.
Her work is driven by a deep well of compassion and a fierce commitment to justice.
(05:00):
Anastacia, welcome to the podcast.
Hi, it's my pleasure and privilege to have this conversation with you today, Aurora.
(05:22):
What can we know about you and your work?
I kind of hate talking about myself and listening to the intro that you gave a few minutes
(05:47):
ago.
That just sounds to me like, wow, those are some big shoes to fall, and I wonder who that
person is.
So, I don't always feel like that Anastacia, but to put it in very simple and I'm going
to try humble terms, I am a primary care provider, a GP, working in a remote fishing village outside
(06:09):
of Cape Town that some of your listeners might have heard of.
It is called Sea Point, and I treat LGBTQIA+ patients, I mean, I treat everyone, but
I certainly have a special interest in treating LGBTQIA+ patients.
I provide a lot of gender affirming healthcare services and manage the hormone therapy for
(06:32):
a lot of trans folk.
In addition to that, I do a bunch of work with, let me say, patients who've experienced
medical trauma over their tricky health conditions like fibromyalgia or parts or connective tissue
disease or et cetera, et cetera, et cetera.
(06:55):
The kind of conditions where you go to the doctor and they don't believe that you have
pain or they look at the labs and say that you're fine or ready where they just tell
you, oh, go lose weight kind of thing, and that will solve all your problems.
So those are the kind of things that I do.
And then in addition to that, I do the occasional bit of activism, which whether or not it's,
(07:18):
I don't know if it's opt in or opt out at this point, we can have another conversation
about consent sometime down the line.
And I do a bit of teaching with medical students at UCT.
Thank you.
I think I would have loved to be one of your students.
(07:40):
I've attended some of your talks and you have a wonderful sense of humor and a talent for
making complicated subjects seem very clear and simple.
How did you come to be involved in this work?
How did you come to serve this community?
Accidently.
(08:00):
I was working in clinical research elsewhere in Cape Town.
It was the first job that I took when we moved to Cape Town.
It was actually the reason that we moved to Cape Town,
my wife and I.
So I was working in clinical research and the company that I was working with landed
(08:21):
on some difficult times, and I resigned and looked for some primary care work in the neighborhood
that we at that point lived in, which was Sea Point, and I found a practice who was looking
for another doctor to come on board and I did so.
(08:42):
And at that point, moving forward, you know, I've, so since the beginning, I have learned
through my own medical trauma that it's very difficult to rely on other people to manage
my own hormone therapy.
I did everything by the book.
Initially, I have the scars from that, you know, those wounds still, still hurt me and
(09:04):
make it difficult to seek my own health care.
And I learned from those experiences now almost a decade ago that if I want to to be cared
for in the best possible way, I've got to do it myself.
So I had the knowledge or at least I had the, you know, I built up the experiential sort
(09:25):
of.
Yeah, education, the, the learn it by doing it sort of thing and learn it by living it.
And I also have always had that moment of reflection where I think well, if I struggle
like this as someone who has an actual medical degree, then what about the people who don't,
(09:50):
which in this country happens to be the majority of trans people who aren't walking around with
medical degrees and prescribing rights.
And I thought, well, that must be a pretty shit experience.
So sorry, am I allowed to swear?
Okay, great.
Got the thumbs up.
So I thought that must be a pretty shitty experience.
And I started offering these services because I mean, no one else would.
(10:15):
And it was just part of what I do is a much smaller part of what I do.
I would say that by now sort of five years later, five and a bit years later, the kind
of specialized work or the niche work that I told you about occupies about 85% of my
(10:35):
clinical time.
So certainly it's grown.
And yeah, that's sort of I didn't set out and say I'm going to be the hormone
doctor.
It just kind of happened that way.
(11:06):
Now, the reason we are here today are the guidelines around gender-affirming health
care.
The South African HIV Clinician Society's gender-affirming health care guideline, which
(11:26):
was published in 2021, is the gold standard for gender-affirming health care in South
Africa.
And it is the most comprehensive and evidence-based set of guidelines for trans health care.
This guideline has been endorsed by a variety of professional and civil society organizations
(11:50):
including the Professional Association for Transgender Health South Africa, the Psychological
Society of South Africa, the WITS Reproductive Health and HIV Institute, the University of
Pretoria's Center for Sexualities, AIDS and Gender, GenderDynamix, Triangle Project
(12:13):
and Be True 2 Me.
You were the lead author of these guidelines, so I can't think of anyone better to talk
about gender-affirming health care.
Now, I believe the guideline was informed by the World Professional Association of Transgender
(12:34):
Health Guidelines, but also adapted and decolonized for the South African context?
WPATH and their guidelines have been around for a long time.
It's called Standards of Care.
It dates back at some point before it was called WPATH.
It was called the Harry Benjamin Institute for...
I don't even want to go there.
(12:55):
There has always been some clinical guideline for the management of trans folks to whatever
extent.
The problem is that these guidelines are developed in and for the Global North and trying to adapt
them to sociocultural situations that are very different to that isn't always easy.
(13:21):
They'll talk about medications and treatments and tests and investigations and things that
we just don't have.
They have resources to the health care system that we just don't have.
We need to find solutions that make sense in this context.
You can't scale it in that sense because it's apples and oranges.
(13:46):
In developing the guidelines, we drew on a wealth of published scientific evidence,
not just the WPATH guidelines, but we really did a very, very, very, very comprehensive
literature review to inform a lot of what we were suggesting in the guidelines.
(14:08):
Throughout that process, we understood that localizing this and giving ownership to this
community here in South Africa for whom we're writing this and recognizing that probably
it will be adapted or have some relevance would be drawn on elsewhere in Africa, particularly
(14:33):
in our neighboring countries.
We had that in mind and we really tried to involve firstly a multidisciplinary team,
so it wasn't just doctors or endocrinologists or psychiatrists, but we really tried to bring
in people from a variety of different professions.
We had psychologists, we had dietitians, we had speech therapists, weighing in on all
(14:56):
of this.
We also looked at social policy and institutional policy, what happens in hospitals, what happens
in prisons, what happens in clinics in terms of handling all of this.
We tried to take this holistic view and by assembling as diverse as we could a team of
(15:18):
authors and also recognizing that this guideline was not ever intended to be the final gospel
truth on gender-affirming care intended to be a first step and knowing that things will
change and that there will be, ideally, you know, there will be new iterations just like
(15:39):
there are with the standards of care, then this was us trying to do right by the community
in as many ways as we possibly could and that was really important to us.
And yet despite all of this evidence and all of the many years of clinical trials and research
(16:02):
reports, the gender-affirming approach is still criticized by some as, quote-unquote,
“gender ideology”.
What are the values that really underpin this guideline?
I think the primary value is just respect for individual autonomy.
(16:24):
You know, we speak about in the guidelines, we say what are the indications for gender
reform and hormone therapy, you know, and number one is that you need to want the treatment.
Number two is that you have gender incongruence and number three is that you are capable of
making a decision.
(16:45):
So the entire power of decision-making as it should be in healthcare rests with the individual
who's accessing services.
Our job isn't to make the decision on anyone's behalf.
I can't say yes, no, here’s your hormones, you don't get hormones, you must have hormones,
(17:08):
I don't get to do that.
I have to use my knowledge training, expertise, experience, skills in order to take the encyclopedic
knowledge that I have around the human body and pharmacology and physiology and all of
that and pick out the little bits that relate to gender-affirming hormone therapy and present
(17:34):
them to, I use “patient”, to present them to the patient in a way that they can understand
and that they can interpret so that they can make a decision that is the best decision for
them at that point in time.
So the value for me that underpins and I mean you can go read the guidelines, they're open
(17:58):
access and peer-reviewed, but they are open access and you can go read in the preamble some of
the values that we as a team have said underpin the guidelines and we do stick to them.
I think for me the most important thing was always going to be respect for autonomy.
Everything that we've done is informed by an approach consistent with medical ethics
(18:19):
which is something else that I've published on in the past.
So we continue to do that and as is ethical and as is in HPCSA and as we are all taught
we should be working on an informed consent basis where people are permitted to have agency
over their own bodies and as you can imagine, not even imagine but as you well know in 2025
(18:46):
in the climate that we live in, even in the Global North or maybe even more so in the
Global North this concept is becoming very, very politicized.
(19:08):
The truth about the access to gender-affirming health care.
Now before we dive into what gender-affirming health care actually comprises, let's talk
(19:31):
about how someone would access gender-affirming health care.
What is the process for an adult to follow before they can begin receiving gender-affirming health care?
So obviously that process is going to differ depending on where you are and on where you're
accessing your services.
So you know I speak about where you are in terms of geography and where you're accessing
(19:55):
services in terms of primary, sorry public versus private and also at which level you
know as a primary, as a secondary, as a tertiary etc.
We, our guidelines and international guidelines are promoting the idea that gender-affirming
(20:15):
care should be available at a primary care level, that it doesn't require necessarily
specialist initiation or intervention.
It isn't yet easily accessible in the public sector in South Africa at a primary care level,
especially now that a lot of the NGO public sector partnership clinics that were providing
(20:39):
the service at primary care are no longer funded, so that does become a little bit tricky.
At this point a patient would have to present to their primary care provider and request
a referral to the transgender clinic for example at Groote Schuur.
This process will look different depending on where in South Africa you are and in some
(21:01):
areas like Limpopo or this might be almost impossible, so it's very very difficult potentially.
It does get a little technically easier in the private sector if you are able to see
a provider who is informed and knowledgeable about the provision of gender-affirming care
(21:24):
or who is willing to learn and who's willing to prescribe the treatment for you, then you
know you would be able to make an appointment with that person, ideally this is what would
happen if you were seeing me and that person would probably give you the information ahead
of, I would give you the information ahead of time to read up a little bit about the
hormones, this would be information that I have personally sourced and vetted and that
(21:46):
I will vouch for as being accurate, there's great information on the internet and there's
also not so great information on the internet, so I would give you that ahead of time.
Some patients would want to do their baseline laboratory investigations ahead of time, so
maybe go and do some blood tests, you would sit with me and we would go through what are
(22:07):
your options, what does it look like, what are the pros, the cons, the risks, the benefits,
the side effects, the consequences, the costs, etc, we go through all of it together, you'd
have ample opportunity to ask questions, we would do a physical examination for you and
then we would collaborate in terms of the decision making on what is the route forward,
(22:28):
are you starting on hormone therapy, when are you starting on hormone therapy, what
kind of hormone therapy are you starting on, so that's kind of what the process would
look like in in private or in an ideal world that is just what the process would look like,
Thank you.
Thank you.
(22:57):
Gender inclusive language 101
The guideline includes some very useful tips on gender inclusive language for practitioners
(23:20):
to use when taking asexual history, but I also think many of these tips would be helpful to
every person listening to this who doesn't regularly interact with gender queer folks.
Which of these tips would you like to share here?
So I think it starts with like, let's not make assumptions about what kind of people are in
(23:43):
what relationships with what other kind of people and what kind of intercourse that they're having,
so you know, it's language like partner instead of boyfriend, girlfriend, husband,
wife, etc, I think it's also important to recognize that people might have multiple partners
and that those partners could be regular partners or they could be sporadic partners,
(24:06):
just making space for people who are potentially polyamorous.
I think it's important for us to find language that is disarmed in terms of referring to anatomy
and body parts, and I think the best way to do this is just to have a conversation either with
the patient or with your partner, depending on whether you are a clinician or someone who's just
(24:30):
getting something nice to find out, you know, how would you like me to refer to this? Is there
any language that you would prefer me to avoid or, you know, a lot of it is just
let's not make assumptions. So, you know, again, let's not lean into like the heteronormativity,
but let's also just recognize that I can't know what's good and right for you,
(24:56):
unless I ask you. And I think maybe here's the number one tip, it's really just this,
is don't be afraid to talk about it. You know, we all are indoctrinated with this ideology
that sexuality is a taboo and that we're not allowed to talk about it. And, you know,
(25:20):
we've, I've discovered one thing is that if you do talk about it, the world doesn't end and
things are actually better for it. So, you know, maybe that's the tip is just practice talking
about it, go look in the mirror and have the conversation with yourself first.
Non-medical gender affirming practices
(25:48):
You mentioned that there is a lot of misinformation about HIV and TGD people out there. There's also
(26:11):
a lot of misinformation and disinformation, even in the media, about other aspects of gender
affirming healthcare, like hormone therapy and surgery. But there are actually also many
non-medical gender affirming practices that many TGD people start with before or even instead of
(26:35):
hormonal or surgical transition. Could you tell us a bit more about these non-medical
gender affirming practices? Yeah, I can and I can tell you that a lot of people start with them
long before medical or surgical intervention. I can tell you that some people start with them
long afterwards and some people start with them at the same time and some people never do them.
(26:57):
And the reason I'm saying all of this is just to reinforce and reiterate the idea that no
two transitions look alike. The roadmap doesn't exist. So, you know, I want to say it's different
for everyone, but it actually just doesn't exist. And no singular transition is more or less valid
(27:17):
than another one for what it does contain or doesn't contain or when it contains it.
And it's for this reason that I refrain from using language like full transition,
even if we're talking about hormone therapy doses, we don't talk about a full dose because that
implies that someone who's on a low dose or someone who's micro dosing is somehow less than. So,
(27:39):
I really don't want to do that. And, you know, it just comes to mind when we say this. But
transition can be so many different things. And, you know, we can divide it up. So, to me,
there are medical interventions. There are surgical interventions. But people can transition legally by
updating their documents. People can transition socially by changing the way that they dress or
(28:02):
using a different name or pronouns. People can pursue things like laser hair removal or
electrolysis or voice training or bodybuilding. You know, each and every one of these can be
gender affirming. And sometimes it is breaking the rules that are associated with gender,
(28:23):
that is actually gender affirming. So, there are so many different ways that people might
affirm their gender. And for some people, it might be binding, you know, putting on a thick
or elastic garment that flattens breast tissue to give the appearance of a more masculine chest
(28:44):
or might be tucking where the external genitalia are folded up in such a way as to render them inconspicuous
in even very revealing clothing or swimwear. But not everyone is going to do this. Not everyone
should have to do this. There shouldn't be a responsibility on anyone to do this. But really
(29:05):
what I'm just trying to illustrate is that, you know, this is a kaleidoscope. I mean,
what I find gender affirming and what you find gender affirming could be very different. So,
we need to really take a much broader look at what gender affirmation is. And cisgender people
do it too, you know. I mean, cisgender men use testosterone or they have treatment for
(29:32):
alopecia or, you know, cisgender women who have augmentation, mammoblasties or face,
that's all gender affirmation because we see these things through a gendered lens. So, you know,
the idea that we could reduce it into these like medical minutiae when the entire concept of
(29:52):
gender affirmation is actually rooted in social structure. And I'm not going to say gender is a
social construct because things are much more nuanced than that. And please, let's not go there.
But, you know, to realize that like makeup, for example, is inherently not a gendered item.
But we insist on seeing it in a gendered way, you know. And so, recognizing that I think the
(30:19):
framework of what constitutes gender affirmation and what practices are gender affirming can be
very, very different for everyone. And this is why reducing or minimalizing this lens that we
consider care, and I'm not going to say healthcare, but I'm going to say care for trans and gender
(30:43):
diverse people to this narrow focus of hormones and surgery, like that really isn't enough, you
know, we should welcome at the clinic, we should welcome people to use the bathroom or the restroom
with which they identify, but we should also provide a neutral space for people who aren't
(31:05):
comfortable in either of those spaces. You know, and it doesn't mean now you have the men's room,
the women's room, and the trans' room that all of the trans' must go to, you know, it's not like
that. But it's really about just figuring out what are the things that are acting actively to
dismantle affirmation, and how do we deal with that. So, you know, I've given you a very broad
(31:30):
and ethereal answer to this question, but I think it almost necessitates that.
Hello, it's me, Aurora. Please excuse me interrupting my own podcast. I'm just here to say that I will
(32:00):
never include third party ads on Intersectional Psychology, which is great because it means
that you can be sure all the mental health information and content shared here is free
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Psychology. Thanks and back to Intersectional Psychology.
(33:34):
The Truth About Hormone Therapy
Now, we get to one of the contentious areas of gender-affirming healthcare,
(34:08):
hormone therapy. So, to start with, what should we know about HT in general?
What you should know about hormone therapy is that all human bodies have, at a baseline,
some oestrogen and some testosterone in varying degrees, but these are both molecules,
(34:28):
substances, let's stick with molecules that are intrinsic to the human body. They're not foreign,
they're not outside elements, they're not these synthetic, dangerous chemicals that people might
make them out to be, and that many of the drugs that we use to treat other conditions actually are.
We are tinkering with the balance between oestrogen and testosterone, but we're doing so
(34:53):
using those exact same molecules and hormones that your body already produces.
And then the other thing to bear in mind is just that we are not trying to do anything that is
beyond physiological limits. So, you know, the body is capable and programmed to and is happy
(35:14):
in certain ranges with these hormones, and this is what we're trying to do with gender-affirming
hormone therapy. So, if you're coming on, you're going on testosterone therapy, I'm not trying
to give you Arnold Schwarzenegger doses of testosterone, I'm trying to give you physiological
doses of testosterone. When is hormone therapy prescribed and when isn't it?
(35:41):
When is hormone therapy prescribed? When someone wants hormone therapy, when they are gender incongruent,
and when they are capable of giving consent, sorry, that's only three things. That is when
hormone therapy is prescribed. There are very, very, very few of what we would call absolute
contraindications to hormone therapy cases where I absolutely cannot give hormone therapy, and that
(36:04):
would be things like if someone has a cancer that is sensitive to one of the hormones, like an
oestrogen-sensitive cancer, if oestrogen is the growth factor, I'm of course not going to give that
person oestrogen. If it's someone who's had a venous thromboembolism or who has a familial
clotting disease, then that could be an absolute contraindication. But other than that, we have
(36:29):
relative contraindications, areas where we have to exercise a little extra caution, not that we
don't exercise the utmost of caution anyway, which we do, and then we have coexisting conditions that
need to be managed alongside. So, high blood pressure doesn't mean you can't have hormone
therapy until you get below a certain measurement, but it does mean that I'm going to manage it at the
(36:54):
same time. Feminising and masculinising hormone therapy is obviously quite different and has
different effects. What should we know about feminising hormone therapy? Feminising hormone
therapy, the specifics can be a little bit different, depending on the case, but the backbone
(37:16):
of it is oestrogen. What we're trying to do with the administration of oestrogen is to promote the
development of what we would call female secondary sexual characteristics, so things like the growth
of breast tissue, things like body fat distribution, things like changing the texture and the oiliness
(37:37):
of skin, things like promoting growth of scalp hair. These are the sort of things that we would
expect from feminising hormone therapy. And how does masculinising hormone therapy work?
Masculinising hormone therapy, the backbone in this case would be testosterone, and we would be
(37:58):
promoting virilisation, which is the increase of muscle mass, it would make the skin oilier,
we would see growth of facial hair, we would see thicker, courser body hair, we would see
probably an increase in libido, we would see an increase in metabolic rate and that sort of thing.
We would also see what we call bottom growth or hypertrophy of the clitoris, and in some instances
(38:24):
we would see the cessation, i.e., it would stop cyclical bleeding.
Now, if someone has already gone through endogenous puberty, there are some effects
of that puberty that can't be reversed through hormone therapy.
What are some of the impacts of puberty that hormone therapy can't change?
(38:48):
What's important to understand here is that hormones, sex hormones, oestrogen and testosterone
have two kinds of effects. They have effects that are reversible and effects that are irreversible.
And this is true whether we speak of exogenous hormones, that means the ones that you buy in the
bottle or endogenous hormones, that means the ones that come out of your body. All of them have
(39:11):
both of these kinds of effects. Testosterone, for example, has a lot more irreversible effects
than oestrogen does, and if someone went through puberty and they were exposed to these high
levels of testosterone, they would have developed some of these irreversible effects of testosterone,
such as the growth of facial hair, such as the thickening of the vocal folds, which causes
(39:32):
someone's voice to drop. Potentially, androgenic alopecia, male pattern baldness, could be irreversible
if it's persisted for long enough. That's the effect of testosterone and its metabolites
on the hair follicles themselves. So these are irreversible effects that we talk about,
(39:53):
and someone who's been exposed to endogenous hormones will experience those. Then on the
other hand, if we speak about oestrogen, what are irreversible effects of oestrogen? Well,
that would be the development of breast tissues. So I'm talking here about structural
breast tissue glands and ducts. If there's fat in breast, which there is, some of that might
(40:14):
distribute away and they might get smaller, but the growth of breast tissue. So if you've gone
through a puberty and you've developed D-cup breasts, those aren't going to go away,
unless something else is done. And then of course, we just have to consider when it comes to things
like skeletal growth and dimensions. So the hormones do have an effect ultimately on how
(40:41):
you grow and for how long you will grow and in what ways you will grow in the shape of bones
and things like that, which are irreversible not by virtue of the hormones, but by virtue of time.
So would it be fair to say that as a TGD person starting hormone therapy,
(41:02):
you're basically experiencing a second puberty? And all of those changes that are irreversible
in endogenous puberty would then also be irreversible after taking hormone therapy?
Yeah, I think it would be unfair to say it, but 100% true. You are going through a second puberty,
(41:22):
and if it was difficult the first time, try doing it when you understand what's going on and how the
world around you works. And you've actually got that sort of lived experience and that wisdom
to then go through a period where your skin becomes oily and pimply and your voice is breaking and so
on. But yeah, the irreversible changes would occur in a second puberty as well. And that's
(41:46):
what we expect to see in people who are going on exogenous hormone therapy.
(42:17):
And now let's talk about surgery. Before we get into specifics, what background information should
we know about gender affirming surgery? I think what we should know is that this is often a facet
of trans experience that the cisgender majority wants to focus on and zoom in on and it attracts
(42:41):
all kinds of just attention and it's almost seen as this is what trans identity is about,
is the sex change operation. And what I think is very important to realize is just that
of trans people who want gender affirming surgery, which is not all of them and doesn't have to be
(43:03):
all of them and no trans person is less valid because they don't want surgery or they don't get
surgery, it is a fraction of people who will actually have access to those procedures.
And so much of trans lived experience is non-surgical, not to say that surgery can't play
a role in it, but just that it's non-surgical. And even to say that surgical experience doesn't
(43:28):
occur in isolation because there's so much that goes on around it that is non-surgical. So to get
lost in that conversation is very unhelpful. If you want to understand trans people better to
have another pin on your ally flag, then don't start by reading up on surgery, it's not going
(43:49):
to get you there. And certainly don't go around and ask your token trans friends about the
surgeries that they've had or the surgeries that they want. There is so much, so much,
so much more to this. The surgeries can be very interesting in terms of anatomy and technique
and so on. Particularly if you do have an interest in surgical, I find it very fascinating to understand
(44:17):
what procedures are being done and how they're being done and what new techniques are being
developed. But that's an interest that's born out of my sort of fascination with surgery in
general and not out of my obsession with what's inside people's pants.
Thanks. As you say, a fraction of trans people who want surgery actually have access to it,
(44:44):
especially here in South Africa. I think in the Western Cape there are only one or two gender
affirming surgeries performed per year in the public sector. And I know that trans people who
inquire about it are told the waiting list for gender affirming surgery here is about 15 years
(45:07):
in the public health system. So it's really not everyone who is going to have such surgeries.
Not everyone wants it and even fewer people have access to it.
And when is surgery prescribed and when isn't it?
The first thing about the surgery, the surgery about surgical intervention is that you need to
(45:31):
want it. I'm not going to name names, but I believe that there are certain gender clinics that
have been in operation in South Africa that had patients sign a contract before they went on
hormone therapy saying that they will at a later date have surgery. We don't do that. We shouldn't
do that. It's an individual choice. It can affect so many different things in so many different
(45:57):
ways. There's healing time, there's complications, there's all sorts of things that go into it.
So who gets surgery, someone who wants surgery, someone who is capable of making that decision,
there is often going to be a requirement for at least an interaction with the mental
healthcare provider who's of suitable qualification to ensure that a patient is competent to make the
(46:22):
decision. So there's still that little bit of gatekeeping involved. And I think it's also
important to realize that surgery isn't enough on its own. I see patients coming in through my door
who had gender-affirming surgery 25 years ago. And since then, no one so much as prescribed
a hormone for these people. They've been walking around with zero testosterone, zero oestrogen,
(46:44):
increasing their risk for osteoporosis, for fractures, for heart disease, for depression,
for all kinds of things. So it's not like you put people on the assembly line and you do surgery
and then off they go. And further to that, it's got to be people who we always consider surgical
risk and the benefit. And someone who is a good candidate for surgery will be someone who is what
(47:09):
we term an aesthetic risk or risk of complications related to other medical conditions is as low
as possible. That if there are other conditions that they've been optimized, that this is someone
who's going to be able to adequately recover and to go through all of the procedures that are
associated with that. Sometimes there's like a little bit of like maintenance that needs to be
(47:31):
done. And you know, it's not something to be taken lightly. But if someone expresses this
persistent desire for a certain procedure, you know, and then we've had the conversation with
them, the informed consent, we've managed the expectations, you know, surgery is never going
to be a silver bullet. It could be that you have intense dysphoria over certain parts of your anatomy
(47:55):
and you will never have that dysphoria adequately relieved without surgery. But you will not
necessarily just need the surgery in order to feel better. So, you know, it's in that case,
it could be necessary, but not sufficient, if that makes some sense. So these are the considerations
around, you know, we don't prescribe surgery, we collaborate with people on a decision, and
(48:24):
then we try to get them access to the interventions that they want or need, and to do so in a way
that is safe and responsible and scientifically sound.
(48:59):
As we wind up this episode, would you like to share what is on the horizon for you?
Not really anything that I can very directly plug. Just to say that there are some exciting things
happening in terms of rolling out at least training on gender-affirming health care
at the primary care level. I don't know how much detail I'm allowed to give on it, so I'm not going
(49:23):
to. And then to say just on an individual or not an individual level, but at least
part of the, on the level of the team and the practice that I run, is just that we are looking
at some ways to actually do some research into the role of narrative agency in a health care,
which I think is very important for both patients and for providers, and that there's a whole lot
(49:46):
of interesting and intersectional conversation to be had around that, and the sort of colonialism
that remains inherent, and the patriarchy that remains inherent in medicine, and how we dismantle
that through voice, you know, whether it is spoken voice or written voice, et cetera.
So I find that to be intriguing, and if I can get funding to do the research, then certainly
(50:11):
I'll be blabbing about it a lot more. That sounds really exciting, and seeing as you didn't mention
it yourself, I'll just plug your book. It is for sale all over. I know Exclusive Books have it here
in South Africa, and it is also available internationally. Just search for “Always Anastacia”
(50:36):
by Anastacia Tomson. I loved reading it. I really enjoyed reading a positive representation
of a trans person in South Africa, and it is written with your usual eloquence and sense of humor.
Thank you. The book, I often forget to mention it because it's nine years old. It's almost going
(51:01):
to be able to go to school by itself, so I forget that it's a thing, and it just keeps coming back,
which I suppose is a good thing. But it also reminds me that I probably need to sit down
and write another one, and I don't know on whose time and on whose coin I'm going to do that,
so we're still trying to figure that out on ours.
Where can listeners go to find out more about you and your work?
(51:25):
For better or worse, I'm infinitely Google-able. The only trap door there is that you have to
spell my surname correctly. It doesn't have an H, and it doesn't have a P. You'll also find me all
over social media under the handle Anaphylaxus. That's got a U-S at the end, not an I-S at the end.
Again, it is a very deliberate and intended misspelling, so it's not really a misspelling, but
(51:49):
you'll find me all over social, and you can also read more about the work that we do at the practice
at myfamily.gp, if you so wish. Anastacia, thank you so much for your time and your insight,
and your extraordinary contributions to trans healthcare in South Africa.
(52:12):
You've not only helped demystify what gender-affirming healthcare actually is,
you've also reminded us that healthcare, at its heart, should be about care.
For anyone listening who thought gender-affirming healthcare was a niche issue or some kind of
(52:33):
political hot potato, today made it clear it's healthcare, full stop. It's evidence-based,
it is life-saving, and when it's done right, it can be profoundly affirming. Not just of gender,
(52:55):
but of humanity. And if you're still wondering how it affects cis people,
maybe it's this. The more we build systems that honour everyone's dignity, the better
they work for all of us. This was just the first episode in our series on the health of
(53:20):
trans and gender-diverse people. In our next installment, we'll be speaking to a mental
health professional about what an affirming therapeutic relationship really looks like,
and how to tell the difference between support and subtle sabotage. Until then, stay curious,
(53:42):
stay compassionate, and please don't believe everything you hear in the WhatsApp groups.
Thank you for listening to Intersectional Psychology. Please follow or subscribe to
the podcast to get every episode. If you enjoyed this episode, please rate and review
(54:04):
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This episode of Intersectional Psychology was researched, written, recorded, and edited
by me, Aurora Brown. For a transcript of this episode, please see the link in the show notes
(54:29):
on your podcast app, or go to intersectionalsychology.com. You can also check the website
or the show notes for a full list of references for this episode.
A video of this episode with closed captions is available on youtube.com forward slash
(54:51):
intersectionalsychology. To support this podcast and get access to bonus content,
including additional episodes and interviews, as well as more guided mindfulness sessions
please go to Patreon.com/IntersectionalPsychology. You can also chat
(55:14):
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Aurora Brown and Intersectional Psychology are committed to the Cite Black Women praxis.
(55:41):
All episodes of Intersectional Psychology are for educational purposes only and are not intended
to be a substitute for professional mental health advice, diagnosis, or treatment.
I, Aurora Brown, am not able to answer specific questions about individual situations.
(56:03):
Always seek the advice of your health provider with any questions you may have regarding a mental
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