In the Global North, access to gender-affirming care for transgender and non-binary youth is increasingly undermined by politically motivated attacks that ignore clinical evidence and patient rights.¹ In this climate, the 2024 position statement by the South African Society of Psychiatrists (SASOP) on the care of transgender and non-binary youth² represents an ethically sound, evidence-informed, and culturally attuned framework that places patient dignity, legal rights, and clinical best practices at its core. The recent scientific letter in this journal from Donkin et al.³ risks undermining this progress by repeating a selectively sceptical and ideologically biased narrative originating from the Global North that fails to reflect either the global scientific consensus or South African constitutional values. This letter defends SASOP’s current position by examining the flaws in Donkin et al.’s critique and source material and affirming the methodological rigour and ethical clarity of recently published guidelines for care of transgender and non-binary youth.^4,5

Donkin et al.’s letter centres much of its case on the findings of The Cass Review, a report on gender identity services for children and young people in England commissioned by National Health Service (NHS) England and NHS Improvement, whose content primarily comprises policy recommendations specific to the NHS.⁶ The Cass Review has been widely criticised for methodological opacity, a lack of stakeholder accountability, and the exclusion of affirming outcome data.^7,8,9 Although The Cass Review acknowledges the importance of ‘research evidence, clinical expertise and patient values’,⁶ it fails to fully meet these criteria. The lead author had no expertise in the treatment of or research into gender dysphoria in children and adolescents, and individuals with lived experience of being transgender had limited input into the process.^7,9 This contravenes best practices for evidence synthesis and guideline development, which call for appropriate subject-matter expertise and meaningful accountability to stakeholders to mitigate bias and strengthen validity.¹⁰ By analogy, a review of cisgender women’s health that overtly excluded clinicians or researchers specialising in the field and rebuffed input from cisgender women themselves would rightly be regarded as biased, uninformed and fundamentally flawed.

Moreover, much of The Cass Review’s framing and conclusions align closely with talking points advanced by US- and UK-based groups that actively oppose gender-affirming care.⁸ This ideological alignment extends to other key sources cited by Donkin et al. In addition to directly citing the misleadingly named Society for Evidence-Based Gender Medicine (SEGM) – a group described by a Yale School of Medicine review as spreading ‘biased and unscientific content’ to restrict access to gender-affirming care¹¹ – five of the citations underpinning Donkin et al.’s arguments are authored by individuals affiliated with SEGM and Genspect.ⁱ Both organisations are documented anti-LGBTQ+ groups¹² and identified as central to what the Southern Poverty Law Center describes as the ‘anti-LGBTQ+ pseudoscience network’.¹³ One of these five sources, the ‘WPATH Files’, attempts to discredit the World Professional Association for Transgender Health (WPATH) through selective and misleading excerpting of posts from internal professional forums.¹⁴ These sources do not constitute a neutral or empirically grounded critique, but rather reflect a coordinated output of a tightly networked, agenda-driven ecosystem.¹⁵ This pervasive ideological backdrop raises serious concerns about the applicability of Donkin et al.’s claims within a South African rights-based clinical context.

Donkin et al. criticise the SASOP position statement for supporting clinical guidelines issued by WPATH¹⁶ and the South African HIV Clinicians’ Society (SAHCS)¹⁷ (Table 1). They take particular issue with the South African guidelines’ legal alignment with the Children’s Act¹⁸ (which provides that children over 12 who demonstrate sufficient maturity can consent to medical treatment), while disregarding the guidelines’ emphasis on the importance of parent or caregiver involvement.

Donkin et al. also fail to engage with recent guidelines from the French Society of Pediatric Endocrinology and Diabetology (SFEDP)⁴ and the German Association of Scientific Medical Societies (AWMF).₅ Both were developed through robust, multidisciplinary and transparent processes. These guidelines conclude that gender-affirming care for adolescents, when provided with comprehensive psychosocial support and informed consent, is effective and appropriate. They explicitly reject the discredited notions of ‘rapid-onset gender dysphoria’ (ROGD) and ‘social contagion’, both invoked in Donkin et al.’s critique.^19,20,21 Instead, they advocate for evidence-based, individualised pathways that acknowledge the fluidity of gender development while centring the well-being of youth.^4,5

Donkin et al.’s letter complains that no explicit mention is made in these guidelines of ‘exploratory therapy’, an undefined process with no established long-term outcome data and informed by a focus on seeking traumatic or pathological roots for gender identity rather than treating it as a neutral outcome.²² They likewise fail to acknowledge that contemporary guidelines for gender-affirming care (Table 1) recognise that desistance and retransition occur and are valid outcomes within a gender-affirming framework. These trajectories are supported without pathologisation or coercion, underscoring the role of clinicians as facilitators of care rather than gatekeepers of identity. By contrast, Donkin et al. focus narrowly on the small minority of patients who have detransitioned with regret, thereby erasing the experiences of the overwhelming majority of transgender youth who benefit from access to care or experience harm and distress when care is denied or made inaccessible.^23,24

Focusing solely on narratives of regret, while ignoring affirming experiences and the harms resulting from denied care, is ethically indefensible. Such a narrow lens distorts the clinical landscape, violates principles of evidence-based medicine, and disregards the human rights of patients. The Psychological Society of South Africa’s (PsySSA) updated 2025 guidelines²⁵ explicitly call on providers to confront their own prejudices and to uphold a non-pathologising, affirming stance. Importantly, these guidelines were authored by a diverse group of psychology professionals grounded in South Africa’s constitutional principles, and they emphasise the clinician’s duty to provide compassionate, respectful and context-sensitive care.²⁵

This context includes South Africa’s rich cultural heritage. Many precolonial societies understood gender as fluid, socially situated, and relational – embedded in roles, responsibilities, and community recognition rather than fixed identity categories.²⁶ Colonial and missionary legal systems suppressed these relational understandings, imposing rigid binaries and sex-at-birth classifications that still constrain how gender diversity is socially and legally navigated today.²⁷ In contemporary South Africa, some communities continue to hold beliefs that ancestors can manifest in descendants of a different gender. While such views are neither universal nor uncontested, they offer some gender-diverse South Africans meaningful cultural frameworks for recognition. For example, a person assigned female at birth may be recognised as mkhulu [grandfather], or someone assigned male as gogo [grandmother].²⁸ Failing to engage with these heterogeneous and historically grounded expressions of gender reflects an implicitly colonial framing. Opening space to challenge rigid gender binaries – and to facilitate social, legal and yes, medical transition – creates room to reclaim expansive and contextually grounded understandings of gender, including decolonial ones.

Crucially, objections such as those raised by Donkin et al. obscure the actual crisis: the widespread lack of access to gender-affirming healthcare for transgender and non-binary youth in South Africa. Gender-affirming care has been available in South Africa since the 1970s, yet services remain overstretched, under-resourced, and inaccessible to most – especially economically marginalised youth and those outside major urban centres.^29,30 While some argue about the pace or appropriateness of care, the far more urgent problem is that most transgender youth are unable to access any care at all. Many avoid health services altogether because of adversarial and/or overtly abusive behaviour from providers.²⁹ Ideologically compromised calls to delay or withdraw services do nothing to address this reality, and in fact risk deepening health inequality.³⁰

The 2024 South African Position Statement on Evidence-Based Care for Transgender and Gender-Diverse Young People – endorsed by a wide coalition of 32 medical, legal and rights organisations, plus over 150 individual clinicians and scholars – affirms the need for accessible, evidence-based and non-discriminatory care, as well as the need to deconstruct rigid gender binaries.³¹ The South African Society of Psychiatrists’ position statement is thus not an outlier. It is rooted in South African jurisprudence and ethical thought, which values the necessity of holistic care and the bodily autonomy and right to self-determination of the child.

In addition to this ethical and legal grounding, SASOP’s endorsement of gender-affirming care is supported by data. International longitudinal studies, although imperfect, demonstrate that access to puberty blockers and gender-affirming hormones can reduce rates of depression, anxiety and suicidality among youth.³² The Cass Review,⁶ by contrast, dismisses many of these findings on narrow methodological grounds while failing to propose feasible alternatives. The WPATH,¹⁶ SAHCS,¹⁷ AWMF⁵ and SFEDP⁴ recognise that perfect data are unattainable in paediatric populations and advocate for the provision of gender-affirming care to adolescents.

Against this backdrop, the claim that SASOP’s position is driven by ‘activism’ rather than science is misguided. The statement was developed by child and adolescent psychiatrists drawing on a robust body of evidence and clinical guidelines.² It reflects the prevailing consensus among leading medical and mental health professionals working in the field of transgender health. At the same time, this dismissal by terming SASOP’s position as activism overlooks the historic role of advocacy in medical progress. Health professionals have long played a critical role in advocating for ethical care in their fields, including the depathologisation of homosexuality, the destigmatisation of HIV and AIDS, and the expansion of mental health services. The South African Society of Psychiatrists’ recognition of the rights of gender-diverse youth continues this tradition of evidence-based professional advocacy. The position statement is far from politically captured; it is scientifically sound and ethically urgent.

Finally, the assertion that youth are incapable of informed consent underestimates the capacity of adolescents, contradicts South African law, and infantilises youth who are navigating their identities. Similar claims have historically been used to deny adolescents’ access to abortion care – arguments ultimately rejected in favour of upholding bodily autonomy and health rights.³³ South Africa’s Children’s Act affirms that minors deemed competent may consent to medical treatment. The South African Society of Psychiatrists’ position statement aligns with this legal standard while emphasising the role of caregivers and mental health professionals in facilitating informed decisions.

In conclusion, SASOP’s position statement on the care of transgender and non-binary youth is clinically rigorous, legally sound and contextually rooted. The statement’s emphasis on psychosocial support, staged interventions and informed consent reflects global best practices – not ideological extremism. Donkin et al.’s critique relies on discredited sources produced by well-documented Global North anti-LGBTQ+ groups, which are out of step with clinical consensus and have been superseded by robust evidence syntheses. It offers no viable alternative beyond delaying or withholding care – approaches that are not neutral but constitute a form of clinical neglect for young people requiring timely, gender-affirming support.

We urge psychiatric professionals to stand firmly in support of an evidence-based, human rights-driven future for transgender youth care in South Africa. This requires structural support and systemic alignment: embedding gender-affirming care into clinical training across levels, expanding rural access through decentralised models, and explicitly including gender-affirming care alongside other key areas such as mental health, sexual and reproductive health, and social support in national adolescent strategies. Finally, this work should meaningfully partner with trans-led organisations in service design and delivery – its raison d’être is to serve, not invalidate, transgender youth.