Nneka Mahote, 32, is excited about her evolving body. Her breasts, now a C-cup bra size, have grown fuller, and her skin feels softer. Her hips, too, are beginning to take shape.

For the past four years, she has been transitioning to a woman, undergoing gender affirming hormone therapy with oestrogen and anti-androgen medication to suppress masculine traits and promote more feminine characteristics.

She has successfully changed her name and identifies as female on her official identity documents.

But now, all of her progress hangs in the balance. It’s been two months since the Nelson Mandela Bay clinic she was receiving treatment at, run by the Wits Reproductive Health & HIV Institute (Wits RHI), shut down. 

The Wits Trans Health Centre is one of several non-profit organisations that closed their doors in January after US President Donald Trump froze US foreign aid — putting an abrupt end to programmes supported by the President’s Emergency Plan For Aids Relief (PEPFAR).  Trump has firmly come out as anti-trans. On his first day in office, he signed an executive order declaring that the U.S. government would recognise only two sexes: male and female. 

The closure of these clinics has left tens of thousands across the country without access to critical gender-affirming healthcare services. Mahote, who is the vice chairperson of the newly formed Nelson Mandela Bay LGBTQ Forum, says she and other clients from the clinic were given enough treatment to last 90 days — the initial duration of the funding freeze.

Mbulelo Xinana, the chairperson of the Forum says, “at the time, we were under the impression that the stop order would last for three months and that everything would return to normal”.

But on February 26, organisations funded by USAID received letters overnight informing them that their grants had been terminated.

Xinana says around 1,500 of their members in Gqeberha have been affected, and have no idea what will happen next. According to UNAIDS, South Africa is home to nearly 180,000 people who identify as transgender, based on data from individuals who choose to self-identify and disclose their gender. 

Limited Transgender Healthcare Services Available

Transgender-specific healthcare services were already scarce in South Africa, with only a few clinics providing such care. The Wits RHI Trans Health Centres in Johannesburg, Gqeberha, Cape Town, and East London and the Anova Health Institute Ivan Toms clinic in Cape Town provided a comprehensive package of care, including HIV prevention, treatment, mental health and gender-affirming services.

“The dedicated transgender clinics showed that it is possible to provide a package of care that includes gender-affirming hormones at primary care. The closure of these clinics is devastating, as gender-affirming hormones are not accessible at government clinics,” says Professor Elma de Vries, chairperson of the Professional Association for Transgender Health South Africa (PATHSA). 

Now the only options available in the public sector are at Steve Biko Academic Hospital in Pretoria, Chris Hani Baragwanath Hospital and Helen Joseph Academic Hospital in Johannesburg, and Groote Schuur Hospital in Cape Town. Mahote is unable to access these services. 

She and other clients of Wits RHI Trans Centres received referral letters to take to private doctors, but the cost is exorbitant.  

“It costs about R650 for a 1mg pill of estrogen and R600 for a 1mg pill of testosterone. This lasts only for four days. Imagine how much you would need in a month,” she says. 

Mahote cannot afford this. 

Medical and Psychological Consequences of Forced Detransition

The impact of suddenly stopping hormone therapy is severe. De Vries explains that halting treatment can lead to a reversal of physical changes, such as a return of facial hair growth in trans women or menstruation in trans men.

“With feminising hormones (oestrogen), a trans woman’s body shape changes with increased fat deposition in breasts, buttocks, hips and thighs. Without hormones, the body shape will change again to what it was before. 

“With masculinising hormones (testosterone), a trans man gains muscle mass and becomes stronger. Testosterone results in changes in body fat distribution, with increased fat in the abdomen and decreased fat in breasts, buttocks and thighs. The skin and body hair become coarser and thicker. 

“Without testosterone, these changes will not be maintained,” she says. 

When Mahote’s treatment runs out at the end of April, she’ll have to shave twice a week instead of once a month. 

Beyond physical changes, the psychological toll is profound. De Vries says this already vulnerable and marginalised group finds itself without safe spaces, having had no say in the decision-making process. 

“The consequences could be significant for transgender individuals, particularly as the sudden cessation of hormone therapy can lead to shifts in hormone levels that may negatively affect their mood and overall well-being.”

The change in hormone levels could lead to depression, anxiety, and a heightened risk of suicidality, she warns. 

Studies indicate that trans and gender diverse people who are not able to access gender-affirming care have a 41% suicidality rate. 

“Forced detransitioning, where individuals experience changes in their secondary sex characteristics, is likely to have a profound impact on their self-esteem and sense of self. It may place them at a greater risk within their communities, as changes in their presentation could make them more vulnerable to discrimination, hate crimes, and violence,” says De Vries.

Fear and Trauma

For Mahote, the fear of losing access to treatment is overwhelming. Growing up, she knew she was not a boy. “I was called Isitabane (gay).” In her second year of university she met transgender individuals, who allowed her to find her true identity. She enjoys being called Sisi (sister), and loves who she is as a woman. That is now in jeopardy. 

“For a long time, I hid my body. For the first time, I could comfortably go to the lady’s bathroom without fear of getting harassed. Now, I have to go back to being referred to as a guy because I can’t afford the drugs. I will go back to the trauma of being called names and using the men’s bathroom.”

The Department of Health has not yet indicated if the gap in trans health services will be filled, and did not respond to our request for comment.

“The most immediate concern is the well-being of people in gender-affirming care. Creating a way for transgender and gender-diverse people to access gender-affirming hormones at government clinics would go a long way in minimising the impact of the funding cuts”, says De Vries. – Health-e News