If someone had told me ten years ago that medical doctors in many countries would support the idea of sex as a spectrum and that HIV doctors in South Africa would be advocating for medically and surgically changing the sex characteristics of children and adolescents with gender distress (with parental consent only optional) I would not have believed them.
It would not just have seemed unlikely; it would have seemed like the sort of plot a satirist might dream up. And yet here we are.
I am part of the South African HIV clinicians tribe. In the late 1980s, I worked in a remote rural hospital in KwaZulu-Natal, where we first started to diagnose HIV. Then followed the dark days before antiretroviral treatment (ART) was an option. Like so many other doctors, nurses, community health workers, counsellors and carers all over South Africa, I felt the despair and frustration of watching helplessly as too many children and young adults died of HIV. In the late 1990s, a psychiatrist friend remarked: “It is like managing a conveyor belt of death.”
Then, in the early 2000s, the option of affordable and effective ART for this out-of-control pandemic gave the first glimmers of hope. Slowly this frail, flickering candlelight grew stronger, and we cautiously let ourselves imagine a better and brighter future for South Africa.
In 2003 I led a team who wrote a funding proposal to PEPFAR (the US President’s Emergency Plan For AIDS Relief) to scale up the ART programme at McCord Hospital in Durban, which enabled us to start 10 000 people on ART.
Fast-forward a decade. Now, in the 2020s, I find myself wondering why many of my former HIV colleagues and comrades appear to have become cadres, promoting the transgender cause.
The velocity and extremity of what has happened globally is extraordinary. Let’s start with “sex as spectrum”. In 2013, the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders, the standard classification system of mental disorders) classified gender dysphoria as psychological distress caused by incongruence between a person’s “gender identity” and their biological sex.
Terminology can cause confusion, so here is a brief explanation: The term sex is used to refer to being either female or male (a binary, not a spectrum) according to different biological, physiological and physical characteristics, such as chromosomes, hormones, reproductive organs and secondary sex characteristics. Gender refers to the various socially constructed roles, behaviours and outward expressions of men and women. Intersex (a term used to describe some Disorders/Differences of Sexual Development – DSDs) is a complex group of congenital conditions caused by disruptions in the typical pathway of sex development during foetal growth. As a result, individuals with DSDs are born with certain physical features that do not fit the typical characteristics of female or male.
Extraordinary contortion
The strongest collective medical voice in South Africa advocating for sex change interventions – aka “transition” or “gender-affirming care” (GAC) – of children and adolescents with gender distress (dysphoria) has been the Southern African HIV Clinicians’ Society (SAHCS). This is an extraordinary contortion of its core mandate. The SAHCS, a highly respected medical society, has been at the forefront of HIV care by providing leadership in South Africa at a very difficult time in our history.
The SAHCS Gender Affirming Healthcare Guideline (GAHG), published in 2021, is a curious departure from the previous work of the Society. “Gender medicine” is not part of its core business. It is something entirely new. In an article in the SA Family Practice Journal which draws heavily on the GAHG, Muller et al state:
“Gender Affirming Healthcare is a relatively new field in medicine and the guideline hopes to address the significant gaps in knowledge and skills of healthcare providers in providing GAHC to transgender and gender diverse people.”
Some of the SAHCS guideline authors are affiliated with the UCT Health Science Faculty, which has hosted three public meetings promoting GAC, including in children and adolescents. The “sex spectrum” idea, and need for GAC are presented as if they are settled truth by a transgender doctor, who teaches medical students at the faculty.
My concern about this “new field of medicine” being taught to medical students is that the practice of medicine has well-established cornerstones: for each patient, clinicians need to take a careful history, do a thorough examination, interpret findings into a careful assessment, and then make a considered treatment plan, guided by good evidence. This is as important for people experiencing gender distress as for people consulting doctors for any other reason. Muller et al regard this traditional medical approach as “gatekeeping” and undermining the autonomy of “transgender and gender diverse” (TGD) people.
I contend that GAC is neither healthcare nor a “new medical field”. It is a “care” construct arising out of an ideology that holds that a human being can be born in the wrong body and therefore needs radical medical interventions to align their physical sex characteristics with their “gender identity”.
To illustrate the difference between traditional medical practice and GAC, I will use the example of HIV. Doctors know that HIV is caused by a virus, which is transmitted in specific ways. It is diagnosed with a blood test and there is a huge body of medical evidence showing that antiretroviral treatment (ART), if taken correctly, will suppress the replication of the virus and protect the immune system. Response to treatment is monitored by measuring the viral load. Although ART needs to be taken for life, it allows people to lead normal lives, including sexually, and to have children.
No diagnostic test
By contrast, clinicians are unsure of the cause of gender-related distress in young people. Muller et al recommend that doctors give cross-sex hormones to TGD children and adolescents. But the terms “transgender” and “gender diverse” are not included in the International Classification of Diseases, or in the DSM-5. There is no diagnostic test or objective way to determine that a young person is “transgender”, or to know whether their gender dysphoria might improve without medical intervention during adolescence. The “gender-affirming” model makes sex-stereotype non-conformity in children a problem requiring a radical medical solution.
Significant shifts are happening internationally: The landmark 2024 Cass review was commissioned by the UK’s National Health Service, and concluded that “gender-affirming medical treatment was based on wholly inadequate evidence”. In 2025 the U.S. Department of Health and Human Services published a 400 page report, Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices, with the same conclusion as the Cass review.
Sweden, Denmark, and Finland now recommend standard psychotherapeutic care in young people with gender-related distress, based on assessing the clinical outcomes of young people who attended gender clinics, and published medical evidence. In April 2025, the UK Supreme Court ruled that the terms “man” and “woman” in the 2010 Equality Act refer to biological sex. This ruling protects biological women’s rights, for example in sport and women’s only spaces.
Back to South Africa: in the SAHCS guideline, GAC recommended for children and adolescents includes blocking puberty with drugs, providing cross-sex hormones, and surgery. These medical interventions carry serious long-term health risks, including sexual dysfunction and sterility. Gender-affirming doctors often refer to “top surgery” and “bottom surgery”, euphemisms that misinform and confuse. These surgeries include amputation of breasts and penises, removal of pelvic organs, and the construction of a pseudo phallus or vagina. Gender-affirming clinicians object to these specific descriptions of what the surgery entails, labelling them as “stigmatising language”.
How can children and adolescents (and their parents) fully grasp the implications for their future sexual and reproductive health? What is particularly troubling is that the SAHCS guideline advocates for consent without parents. A concept that would have sounded nightmarish in 2015 is now printed blandly in the guideline, as if it were the natural evolution of children’s rights. The fact that children are part of families who need to support them lifelong, is undermined.
Retooled themselves
How did it happen that South African clinicians trained to treat a lethal virus have retooled themselves as arbiters of gender identity, and are advocating for poorly evidenced, radical endocrine and surgical interventions despite having no past expertise in mental health conditions in children, adolescents and young adults, or in endocrinology or surgery?
They were positioned to do this not because of clinical expertise but because they already sat at the nexus of rights discourse, donor money and vulnerable populations. What has happened is not just a medical shift. It is a mix of postmodern philosophy (“reality is constructed”), rights absolutism (“denial is harm”), and bureaucratic capitulation (“guidelines must include the new trans orthodoxy”), which has produced outcomes that should evoke deep concern in medical doctors.
The bizarre reality is that trans ideology has been smuggled into the global control rooms of medicine, law and culture, and the rest of society “adapted” because resistance was too difficult or had serious career-limiting implications. The Southern African HIV Clinicians’ Society bought into the new global groupthink.
When activists claim that “trans rights are human rights”, they strategically link trans rights with the rights of all those represented in the LGBTQIA+ umbrella and suggest that those questioning the evidence for GAC are questioning the concept of human rights itself. LGBTQIA+ stands for lesbian, gay, bisexual, transgender, queer, intersex and asexual, with the “plus” representing other sexual identities. The acronym implies that these identities are all linked and share the same battle for recognition and acceptance. However, “LGB” and “I” are not the same as “T”. LGB refers to sexual orientation, which does not need any medical intervention. Intersex refers to very rare conditions that may or may not need specific medical and surgical treatment.
While I have been following international developments with bemused concern, what has really disturbed me has been how the HIV sector became the transgender Trojan Horse in South Africa. I have puzzled over why this medical field became the local driver of transgender ideology and its “clinical” offshoot, GAC. It feels like the stuff of George Orwell’s novel 1984. If anyone in 2015 had written an Orwellian vignette in which HIV clinicians were leading the charge for medically and surgically changing children’s sex characteristics, an editor would have said: “Too implausible, too extreme”. But satire can become prophecy. Orwell’s Newspeak in 1984 was caricature, but in recent years universities started issuing pronoun codes. The craziest conceits of one decade can be the “received wisdom” of the next, if driven by the right combination of ideology, institutional capture and moral righteousness.
Power dynamics
I have struggled to understand why this particular conception of “gender” has been promoted in South Africa by HIV clinicians. The HIV crisis highlighted painfully the societal effects of relationships between the sexes (a traditional feminist understanding of “gender”) and how this played out in power dynamics, expectations of men and women’s behaviour, as well as stigma against gay and lesbian people and gender-based violence against women. What would it have meant to “affirm gender” when facing the deadly HI virus? It would have required affirming a focus on understanding power dynamics, and cultures of human sexuality and sexual behaviour.
Senior South African medical academics are co-authors of a recent article that explicitly frames “gender-affirming healthcare as a test of justice” and links this cause directly to HIV care. They equate having concerns about GAC with AIDS denialism. They accuse those who point out the lack of evidence for GAC in minors (such as the Cass Review) as “weaponising caution”:
South Africa’s painful history with AIDS denialism reminds us of the consequences of politicized health care. Even as science affirmed the efficacy of antiretrovirals, misinformation, stigma, and bureaucratic inertia delayed life-saving treatment. Activists and clinicians pushed back, demanding that the best available evidence guide care, not fear or ideology […] Just as early HIV care was blocked by calls for more evidence, TGD youth are today denied timely care under the guise of caution. New forms of disinformation such as “rapid onset gender dysphoria” or “social contagion” theories mirror tactics used by HIV denialist, anti-vaccine and anti-abortion movements to provoke moral panic… While experts debate, TGD youth bear the consequences by facing harm, stigma, delay, and denial of care in the crossfire. There is no denying that there is an increasing number of young people who are in distress due to their gender identity… Denying care while waiting for long-term data repeats the same harmful logic that once delayed HIV treatment.
The HIV sector was perfectly placed to take on a hero-saviour role: politically moralised, donor-funded, activist-allied and institutionally powerful. It starts with the legacy of HIV as a rights-framed epidemic: HIV care in SA was never only about virology. It was fought as a human rights struggle against stigma, apartheid-era neglect, and later President Mbeki’s AIDS denialism. Doctors in the HIV field became politicised: they were not only clinicians, but advocates and activists. “Access to treatment is a right” became the moral baseline.
Respect and dignity
I was among thousands of activists who marched to Parliament in 2003 demanding ART for our patients. Having lived through the terrible apartheid years and then the devastating South African HIV pandemic, I am deeply committed to human rights and the need for respect and dignity for all people. However, trans activist clinicians have repurposed the notion of a human right, and this ethos carried over wholesale into gender medicine: if ART is a right, then gender-affirming hormones are a right too.
HIV programmes became part of the global donor machinery. Through PEPFAR, and other funders, billions poured into South Africa for HIV care. By the mid-2010s, donors in the Global North began supporting integration of “trans health” into HIV projects. South African clinicians and NGOs dependent on HIV money started to provide “gender-affirming services”. The Desmond Tutu HIV Foundation changed its name to the Desmond Tutu Health Foundation to reflect its broader set of funded activities.
HIV programmes were already working with sexual minorities and young people, and funding for HIV care became explicitly tied to vulnerable “key populations”, including MSM (men who have sex with men), “trans women” (men who identify as women) and sex workers. Existing outreach infrastructure facilitated HIV programmes embarking on GAC, especially since mainstream medical disciplines were more cautious.
While disciplines such as paediatrics, psychiatry and endocrinology remained focused – while under-resourced – on priority health challenges, HIV programmes, with their large, donor-funded workforce primed for activism, became de facto promoters of GAC in South Africa. With no oversight, HIV clinicians uncritically stepped into a role they were never trained for, and unfettered by the rigours of scientific method, boldly promulgate “Gender-Affirming Healthcare for South Africa”.
And finally, there was the moral halo effect. HIV clinicians are culturally seen as heroes: they fought denialism, rolled out ART, saved millions of lives. That makes their pronouncements carry moral weight. When they say that 12-year-olds have the capacity to consent to radical “gender-affirming” interventions, it sounds like medical experts speaking, not ideologues.
The extent of the involvement of the HIV clinician community in this new role, and the consequences, is described in an article: Will Trump’s PEPFAR Cuts End Transgender Mainstreaming in South Africa?
South Africa, home to over 8 million people living with HIV, has historically been the largest recipient of funding from PEPFAR. The Wits Reproductive Health and HIV Institute is just one institution that has received hundreds of millions of dollars via PEPFAR. It has directed… a portion of this funding towards advancing “transgender rights”, including… medicalization at primary healthcare level. Amongst other projects, Wits RHI used PEPFAR funding to support the development of the 2021 Southern African HIV Clinicians’ Society “Gender-Affirming Healthcare Guideline”. These guidelines, authored by members of the South African chapter of WPATH, promote the “informed consent, affirmation-only” approach, with.. no lower age limit.
Ironically, HIV clinicians embracing GAC may indirectly result in people with HIV dying: In recent years some South African NGOs folded GAC and trans advocacy into the package of PEPFAR- and USAID-linked programmes. In 2025, this became political provocation. The new US Republican administration has cast “gender ideology” as emblematic of progressive overreach and something to defund outright, both at home and abroad. When aid money is visibly being channelled into trans-related initiatives in recipient countries, it provides an easy rallying cry: why are American taxpayers funding sex changes in Africa instead of fixing roads at home?
Pretext
The unintended consequence is that by aligning HIV programmes with transgender rights, trans advocates and NGOs may have handed politicians the pretext to slash all the programmes. The cuts don’t just affect gender clinics – they disrupt ART provision, viral load monitoring and prevention campaigns. That collateral damage translates into preventable illness and deaths. Tying survival-critical HIV care to Global North culture-wars has exposed millions of people in the Global South to political backlash and serious health consequences.
Readers might wonder what motivated me to write an article which may antagonise some HIV colleagues. It is unclear whether the HIV Clinicians’ Society board consulted their general members, who may not hold the same views as they do, about this issue. Some HIV clinicians may think that history will not look kindly on this medical experiment.
I am a member of First Do No Harm SA (FDNHSA), a voluntary association of professionals committed to safeguarding evidence-based medical practice. Since April 2024, FDNHSA has tried to engage with the board of the SA HIV Clinicians’ Society to raise concerns about its gender-affirming guideline “for South Africa”. We have formally requested that the guideline be retracted because there are significant concerns about how it was developed and published, which do not follow international best practice. The GAHG was rated 17/100 for rigour of development in commissioned research.
FDNHSA’s concerns about the GAHG have not been taken seriously by the HIV Clinicians Society board. This is the reason for making it visible to the general public, and to a broader group of HIV clinicians.
“The further a society drifts from the truth, the more it will hate those who speak it” – George Orwell
I would like to thank those who have helped with reviewing and editing this article. I cannot acknowledge them publicly but they know who they are.